Network Adequacy Standards; Maximum Travel Time and and Distance Standards by Provider Type; Other Maximum Distance Standard Requirements Commissioner Authority; Maximum Appointment Wait Time Standards; Examination and Fees; Public Hearing on Network Adequacy Standards Waivers; Effect of Network Adequacy Standards on Balance Billing Prohibitions
Section 1301.0055. Network Adequacy Standards
(a) The commissioner shall by rule adopt network adequacy standards that:
(1) require an insurer offering a preferred provider benefit plan to:
(A) monitor compliance with network adequacy standards, including provisions of this chapter relating to network adequacy, on an ongoing basis, reporting any material deviation from network adequacy standards to the department within 30 days of the date the material deviation occurred; and
(B) promptly take any corrective action required to ensure that the network is compliant not later than the 90th day after the date the material deviation occurred unless:
(i) there are no uncontracted licensed physicians or health care providers in the affected county; or
(ii) the insurer requests a waiver under this subsection.
(2) ensure availability of, and accessibility to, a full range of contracted physicians and health care providers to provide current and projected utilization of health care services for adult and minor insureds.
(3) may allow a waiver for a departure from network adequacy standards for a period not to exceed one year if the commissioner determines after receiving public testimony at a public hearing under Section 1301.00565 that good cause is shown and posts on the department’s Internet website the name of the preferred provider benefit plan, the insurer offering the plan, each affected county, the specific network adequacy standards waived, and the insurer’s access plan;
(4) require disclosure by the insurer of the information described by Subdivision (3) in all promotion and advertisement of the preferred provider benefit plan for which a waiver is allowed under that subdivision;
(5) except as provided by Subdivision (6), limit a waiver from being issued to a preferred provider benefit plan:
(A) more than twice consecutively for the same network adequacy standard in the same county unless the insurer demonstrates, in addition to the good cause described by Subdivision (3), multiple good faith attempts to bring the plan into compliance with the network adequacy standard during each of the prior consecutive waiver periods; or
(B) more than a total of four times within a 21-year period for each county in a service area for issues that may be remedied through good faith efforts; and
(6) authorize the commissioner to issue a waiver that would otherwise be unavailable under Subdivision (5) if the waiver request demonstrates, and the department confirms annually, that
there are no uncontracted physicians or health care providers in the area to meet the specific standard for a county in a service area.
(b) The standards described by Subsection (a)(2) must include factors regarding time, distance, and appointment availability. The factors must:
(1) require that all insureds are able to receive an appointment with a preferred provider within the maximum travel times and distances established under Sections 1301.00553 and 1301.00554;
(2) require that all insureds are able to receive an appointment with a preferred provider within the maximum appointment wait times established under Section 1301.00555;
(3) require a preferred provider benefit plan to ensure sufficient choice, access, and quality of physicians and health care providers, in number, size, and geographic distribution, to be capable of providing the health care services covered by the plan from preferred providers to all insureds within the insurer’s designated service area, taking into account the insureds’ characteristics, medical conditions, and health care needs, including:
(A) the current utilization of covered health care services within the counties of the service area; and
(B) an actuarial projection of utilization of covered health care services, physicians, and health care providers needed within the counties of the service area to meet the needs of the number of projected insureds;
(4) require a sufficient number of preferred providers of emergency medicine, anesthesiology, pathology, radiology, neonatology, oncology, including medical, surgical, and radiation
oncology, surgery, and hospitalist, intensivist, and diagnostic services, including radiology and laboratory services, at each preferred hospital, ambulatory surgical center, or freestanding
emergency medical care facility that credentials the particular specialty to ensure all insureds are able to receive covered benefits, including access to clinical trials covered by the health benefit plan, at that preferred location;
(5) require that all insureds have the ability to access a preferred institutional provider listed in Section 1301.00553 within the maximum travel times and distances established under Section 1301.00553 for the corresponding county classification;
(6) require that insureds have the option of facilities, if available, of pediatric, for-profit, nonprofit, and tax-supported institutions, with special consideration to contracting with:
(A) teaching hospitals that provide indigent care or care for uninsured individuals as a significant percentage of their overall patient load; and
(B) teaching facilities that specialize in providing care for rare and complex medical conditions and
conducting clinical trials;
(7) require that there is an adequate number of preferred provider physicians who have admitting privileges at one or more preferred provider hospitals located within the insurer’s designated service area to make any necessary hospital admissions;
(8) provide for necessary hospital services by requiring contracting with general, pediatric, specialty, and psychiatric hospitals on a preferred benefit basis within the insurer’s designated service area, as applicable;
(9) ensure that emergency care, as defined by Section 1301.155, is available and accessible 24 hours a day, seven days a week, by preferred providers;
(10) ensure that covered urgent care is available and accessible from preferred providers within the insurer’s designated service area within 24 hours for medical and behavioral health conditions;
(11) require an adequate number of preferred providers to be available and accessible to insureds 24 hours a day, seven days a week, within the insurer’s designated service area; and
(12) require sufficient numbers and classes of preferred providers to ensure choice, access, and quality of care across the insurer’s designated service area.
(c) Subsection (b)(6) does not apply to an exclusive provider benefit plan if the plan has:
(1) contracted with preferred provider hospitals in sufficient number capable of meeting the covered inpatient and outpatient health care benefits for current and actuarially
projected utilization in accordance with Subsection (b)(3); or
(2) received a waiver under Subsection (a).
See generally https://law.justia.com/codes/texas/2022/insurance-code/title-8/subtitle-d/chapter-1301/subchapter-a/. This section was amended in 2023 by HB 3359 (2023). See https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=HB3359
The following sections 1301.00553, 1301.00554, and 1301.00555 were added by HB 3359 (2023). See https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=HB3359
Section 1301.00553. Maximum Travel Time and Distance Standards by Preferred Provider Type
(a) In this section, “maximum distance” means the miles calculated to drive by automobile within
a service area to a particular type of preferred provider.
(b) For purposes of this section, each county in this state is classified as a large metro, metro, micro, or rural county, or a county with extreme access considerations as determined by the
federal Centers for Medicare and Medicaid Services by population and density thresholds as of March 1, 2023.
Special note! The next sections (c) through (d) contain an extensive chart prescribing the time and distance requirements that various provider types in different geographic areas must satisfy, unless a waiver applies. The chart is difficult to reproduce here. But the following are the chart headings that will give the user an idea of how the time and distance requirements are organized:
(c) Maximum travel time in minutes and maximum distance in miles for preferred provider benefit plans by preferred provider type for each large metro county are:
(1) for the following physicians, as designated by physician specialty:
(2) for health care practitioners in the following disciplines:
(3) for the following types of institutional providers:
4) for the following settings:
(d) Maximum travel time in minutes and maximum distance in miles for preferred provider benefit plans by preferred provider type for each metro county are:
(1) for the following physicians, as designated by physician specialty:
(2) for health care practitioners in the following disciplines:
(3) for the following types of institutional providers:
(4) for the following settings:
(e) Maximum travel time in minutes and maximum distance in miles for preferred provider benefit plans by preferred provider type for each micro county are:
(1) for the following physicians, as designated by physician specialty:
(2) for health care practitioners in the following disciplines:
(3) for the following types of institutional providers:
(4) for the following settings:
(f) Maximum travel time in minutes and maximum distance in miles for preferred provider benefit plans by preferred provider type for each rural county are:
(1) for the following physicians, as designated by physician specialty:
(2) for health care practitioners in the following disciplines:
(3) for the following types of institutional providers:
(4) for the following settings:
(g) Maximum travel time in minutes and maximum distance in miles for preferred provider benefit plans by preferred provider type for each county with extreme access considerations are:
(1) for the following physicians, as designated by physician specialty:
(2) for health care practitioners in the following disciplines:
(3) for the following institutional providers:
(4) for the following settings:
Section 1301.00554. Other Maximum Distance Standard Requirements; Commissioner Authority
(a) In this section, “maximum distance” has the meaning assigned by Section 1301.00553.
(b) For a physician specialty not specifically listed in Section 1301.00553, the maximum distance, in any county classification, is 75 miles.
(c) When necessary due to utilization or supply patterns, the commissioner by rule may decrease the base maximum travel time and distance standards listed in this section or Section 1301.00553
for specific counties.
Section 1301.00555. Maximum Appointment Wait Time Standards
An insurer must ensure that:
(1) routine care is available and accessible from preferred providers:
(A) within three weeks for medical conditions; and
(B) within two weeks for behavioral health conditions; and
(2) preventive health care services are available and accessible from preferred providers:
(A) within two months for a child, or earlier if necessary for compliance with recommendations for specific preventive health care services; and
(B) within three months for an adult.
Section 1301.0056. Examinations and Fees
(a) The commissioner shall by rule adopt a process for the commissioner to examine a preferred provider benefit plan before an insurer offers the plan for delivery to insureds to determine
whether the plan meets the quality of care and network adequacy standards of this chapter. An insurer may not offer a preferred provider benefit plan or an exclusive provider benefit plan before the commissioner determines that the network meets the quality of care and network adequacy standards of this chapter or the insurer receives a waiver under Section 1301.0055.
(a-1) An insurer is subject to a qualifying examination of the insurer’s preferred provider benefit plans and subsequent quality of care and network adequacy examinations by the commissioner at least once every three years, in connection with a public hearing under Section 1301.00565 concerning a material deviation from network adequacy standards by a previously authorized plan or a request for a waiver of a network adequacy standard, and whenever the commissioner considers an examination necessary. Documentation provided to the commissioner during an examination conducted under this section is confidential and is not subject to disclosure as public information under Chapter 552, Government Code.
(b) An insurer examined under this section shall pay the cost of the examination in an amount determined by the commissioner.
(c) The department shall collect an assessment in an amount determined by the commissioner from the insurer at the time of the examination to cover all expenses attributable directly to the examination, including the salaries and expenses of department employees and all reasonable expenses of the department necessary for the administration of this chapter.
(d) The department shall deposit an assessment collected under this section to the credit of the account described by Section 401.156(a). Money deposited under this subsection shall be used to pay the salaries and expenses of examiners and all other expenses relating to the examination of insurers under this section.
(e) Rules adopted under this section must require insurers to provide access to or submit data or information necessary for the commissioner to evaluate and make a determination of compliance
with quality of care and network adequacy standards. The rules must require insurers to provide access to or submit data or information that includes:
(1) a searchable and sortable database of network physicians and health care providers by national provider identifier, county, physician specialty, hospital privileges and credentials, and type of health care provider or licensure, as applicable;
(2) actuarial data of current and projected number of insureds by county;
(3) actuarial data of current and projected utilization of each preferred provider type listed in Section 1301.00553 and described by Section 1301.00554 by county; and
(4) any other data or information considered necessary by the commissioner to make a determination to authorize the use of the preferred provider benefit plan in the most efficient and
effective manner possible.
With regard to section 1301.0056, see generally https://law.justia.com/codes/texas/2022/insurance-code/title-8/subtitle-d/chapter-1301/subchapter-a/
Section 1301.0056 was amended in 2023 by HB 3359 (2023). See https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=HB3359
Section 1301.00565. Public Hearing on Network Adequacy Adequacy Standards Waivers
(a) In this section, “good faith effort” means honesty in fact, timely participation, observance of reasonable commercial standards of fair dealing, and prioritizing patients’ access to in-network care.
(b) The commissioner shall set a public hearing for a determination of whether there is good cause for a waiver when an insurer:
(1) requests a waiver that does not satisfy Section 1301.0055(a)(6);
(2) requests a waiver that the commissioner does not deny; and
(3) does not complete corrective action for a material deviation reported under Section 1301.0055.
(c) The commissioner shall notify affected physicians and health care providers that may be the subject of a discussion of good faith efforts on behalf of the insurer to meet network adequacy
standards and provide the physicians and health care providers with an opportunity to submit evidence, including written testimony, and to attend the public hearing and offer testimony either in person or virtually. An out-of-network physician or hospital, including a physician group or health care system referenced in the insurer’s waiver request or notice of material deviation, may not be identified by name at the hearing unless the physician or hospital consents to the identification in advance of the hearing.
(d) At the hearing, the commissioner shall consider all written and oral testimony and evidence submitted by the insurer and the public pertinent to the requested waiver, including:
(1) the total number of physicians or health care providers in each preferred provider type listed in Section 1301.00553 within the county and service area being submitted for the waiver and whether the insurer made a good faith effort to contract with those required preferred provider types to meet network adequacy standards of this chapter;
(2) the total number of facilities, and availability of pediatric, for-profit, nonprofit, tax-supported, and teaching facilities, within the county and service area being submitted for a waiver and whether the insurer made a good faith effort to contract with these facilities and facility-based physicians and health care providers to meet network adequacy standards of this chapter;
(3) population, density, and geographical information to determine the possibility of meeting travel time and distance requirements within the county and service area being submitted for
a waiver; and
(4) availability of services, population, and density within the county and service area being submitted for the waiver.
(e) The commissioner may not consider a prohibition on balance billing in determining whether to grant a waiver from network adequacy standards.
(f) The commissioner may not grant a waiver without a public hearing.
(g) Except as provided by this subsection, any evidence submitted to the commissioner as evidence for the public hearing that is proprietary in nature is confidential and not subject to disclosure as public information under Chapter 552, Government Code. Information related to provider directories, credentials, and privileges, estimates of patient populations, and actuarial
estimates of needed providers to meet the estimated patient population is not protected under this subsection.
(h) A policyholder is entitled to seek judicial review of the commissioner’s decision to grant a waiver under this section in a Travis County district court. Review by the district court under
this subsection is de novo.
Section 1301.00565 was added in 2023 by HB 3359 (2023). See https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=HB3359
Section 1301.00566. Effect of Network Adequacy Standards on Balance Billing Prohibitions
After a network adequacy standards waiver is granted by the commissioner, an insurer may
refer to the provisions prohibiting balance billing under Sections 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable, in an access plan submitted to the department for the sole purpose of
explaining how the insurer will coordinate care to limit the likelihood of a balance bill for services subject to those provisions and not to justify a departure from network adequacy standards.
Section 1301.00566 was added in 2023 by HB 3359 (2023). See https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=HB3359