Current through Reg. 50, No. 13; March 28, 2025
(a) An
insurer must develop and maintain an ongoing quality improvement (QI) program
designed to objectively and systematically monitor and evaluate the quality and
appropriateness of care and services provided within an exclusive provider
benefit plan and to pursue opportunities for improvement. The QI program must
be continuous and comprehensive, addressing both the quality of clinical care
and the quality of services. The insurer must dedicate adequate resources, like
personnel and information systems, to the QI program.
(1) Written description. The QI program must
include a written description of the QI program that outlines program
organizational structure, functional responsibilities, and meeting
frequency.
(2) Work plan. The QI
program must include an annual QI work plan designed to reflect the type of
services and the population served by the exclusive provider benefit plan in
terms of age groups, disease categories, and special risk status. The work plan
must:
(A) include objective and measurable
goals, planned activities to accomplish the goals, time frames for
implementation, responsible individuals, and evaluation methodology;
and
(B) address each program area,
including:
(i) network adequacy, which
includes availability and accessibility of care, including assessment of open
and closed physician and individual provider panels;
(ii) continuity of medical and health care
and related services;
(iv) the adoption
and periodic updating of clinical practice guidelines or clinical care
standards that:
(I) are approved by
participating physicians and individual providers;
(II) are communicated to physicians and
individual providers; and
(III)
include preventive health services;
(v) insured, physician, and individual
provider satisfaction;
(vi) the
complaint process, complaint data, and identification and removal of barriers
that may impede insureds, physicians, and providers from effectively making
complaints against the insurer;
(vii) preventive health care through health
promotion and outreach activities;
(viii) claims payment processes;
(ix) contract monitoring, including oversight
and compliance with filing requirements;
(x) utilization review processes;
(xii) insured services; and
(xiii) pharmacy services, including drug
utilization.
(3) Evaluation. The QI program must include
an annual written report on the QI program, which includes completed
activities, trending of clinical and service goals, analysis of program
performance, and conclusions.
(4)
Credentialing. An insurer must implement a documented process for selection and
retention of contracted preferred providers that complies with §
3.3706(c) of
this title (relating to Designation as a Preferred Provider, Decision to
Withhold Designation, Termination of a Preferred Provider, Review of
Process).
(5) Peer review. The QI
program must provide for a peer review procedure for physicians and individual
providers, as required in the Medical Practice Act, Occupations Code Chapters
151 - 164. The insurer must designate a credentialing committee that uses a
peer review process to make recommendations regarding credentialing
decisions.
(b) The
insurer's governing body is ultimately responsible for the QI program.
(1) The governing body must appoint a quality
improvement committee (QIC) that:
(A) must
include practicing physicians and individual providers;
(B) may include one or more insured(s) from
throughout the exclusive provider benefit plan's service area; and
(C) must ensure that any insured appointed to
the QIC is not an employee of the insurer.
(2) The governing body must approve the QI
program.
(3) The governing body
must approve an annual QI plan.
(4)
The governing body must meet no less than annually to receive and review
reports of the QIC or its subcommittees and take action when
appropriate.
(5) The governing body
must review the annual written report on the QI program.
(c) The QIC must evaluate the overall
effectiveness of the QI program.
(1) The QIC
may delegate QI activities to other committees that may, if applicable, include
practicing physicians, individual providers, and insureds from the service
area.
(A) All committees must collaborate and
coordinate efforts to improve the quality, availability, and accessibility of
health care services.
(B) All
committees must meet regularly and report the findings of each meeting,
including any recommendations, in writing to the QIC.
(C) If the QIC delegates any QI activity to
any subcommittee, then the QIC must establish a method to oversee each
subcommittee.
(2) The
QIC must use multidisciplinary teams, when indicated, to accomplish QI program
goals.
(d) In reviewing
an insurer's quality improvement program, the department will presume that the
insurer is in compliance with statutory and regulatory requirements regarding
the insurer's quality improvement program if the insurer has received
nonconditional accreditation or certification specific and germane to the
insurer's quality improvement program by the National Committee for Quality
Assurance, the Joint Commission, URAC, or the Accreditation Association for
Ambulatory Health Care. However, if the department determines that an
accreditation or certification program does not adequately address a material
Texas statutory or regulatory requirement, the department will not presume the
insurer to be in compliance with that requirement.
