Tex. Ins. Code 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 (Public Hearing on Network Adequacy Standards Waivers) 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 (Maximum Travel Time and Distance Standards by Preferred Provider Type) and 1301.00554 (Other Maximum Distance Standard Requirements; Commissioner Authority);

(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 (Maximum Appointment Wait Time Standards);

(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 (Maximum Travel Time and Distance Standards by Preferred Provider Type) within the maximum travel times and distances established under Section 1301.00553 (Maximum Travel Time and Distance Standards by Preferred Provider Type) 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 (Emergency Care), 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).
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 2, eff. June 19, 2009.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359), Sec. 5, eff. September 1, 2023.

Source: Section 1301.0055 — Network Adequacy Standards, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1301.­htm#1301.­0055 (accessed Jun. 5, 2024).

1301.001
Definitions 1301.002
Nonapplicability to Dental Care Benefits 1301.003
Preferred Provider Benefit Plans and Exclusive Provider Benefit Plans Permitted 1301.005
Availability of Preferred Providers 1301.006
Availability of and Accessibility to Health Care Services 1301.007
Rules 1301.008
Conflict with Other Law 1301.009
Annual Report 1301.010
Balance Billing Prohibition Notice 1301.0041
Applicability 1301.0042
Applicability of Insurance Law 1301.0045
Construction of Chapter 1301.0046
Coinsurance Requirements for Services of Nonpreferred Providers 1301.0051
Exclusive Provider Benefit Plans: Quality Improvement and Utilization Management 1301.051
Designation as Preferred Provider 1301.052
Designation of Advanced Practice Nurse or Physician Assistant as Preferred Provider 1301.0052
Exclusive Provider Benefit Plans: Referrals for Medically Necessary Services 1301.053
Appeal Relating to Designation as Preferred Provider 1301.0053
Exclusive Provider Benefit Plans: Emergency Care 1301.054
Notice to Practitioners of Preferred Provider Benefit Plan 1301.0055
Network Adequacy Standards 1301.055
Complaint Resolution 1301.0056
Examinations and Fees 1301.056
Restrictions on Payment and Reimbursement 1301.0057
Access to Out-of-network Providers 1301.057
Termination of Participation 1301.0058
Protected Communications by Preferred Providers 1301.058
Economic Profiling 1301.059
Quality Assessment 1301.060
Compensation on Discounted Fee Basis 1301.0061
Terms of Enrollee Eligibility 1301.061
Preferred Provider Networks 1301.062
Preferred Provider Contracts Between Insurers and Podiatrists 1301.063
Contract Provisions Relating to Use of Hospitalist 1301.064
Contract Provisions Relating to Payment of Claims 1301.065
Shifting of Insurer’s Tort Liability Prohibited 1301.066
Retaliation Against Preferred Provider Prohibited 1301.067
Interference with Relationship Between Patient and Physician or Health Care Provider Prohibited 1301.068
Inducement to Limit Medically Necessary Services Prohibited 1301.069
Services Provided by Certain Physicians and Health Care Providers 1301.101
Definition 1301.102
Submission of Claim 1301.103
Deadline for Action on Clean Claims 1301.104
Deadline for Action on Pharmacy Claims 1301.105
Audited Claims 1301.106
Claims Processing Procedures and Claims Payment Processes 1301.107
Contractual Waiver and Other Actions Prohibited 1301.108
Attorney’s Fees 1301.109
Applicability to Entities Contracting with Insurer 1301.131
Elements of Clean Claim 1301.132
Overpayment 1301.133
Verification 1301.134
Coordination of Payment 1301.135
Preauthorization of Medical and Health Care Services 1301.136
Availability of Coding Guidelines 1301.137
Violation of Claims Payment Requirements 1301.138
Applicability to Entities Contracting with Insurer 1301.139
Legislative Declaration 1301.140
Out-of-pocket Expense Credit 1301.151
Insured’s Right to Treatment 1301.152
Continuing Care in General 1301.153
Continuity of Care 1301.154
Obligation for Continuity of Care of Insurer 1301.155
Emergency Care 1301.156
Payment of Claims to Insured 1301.157
Plain Language Requirements 1301.158
Information Concerning Preferred Provider Benefit Plans 1301.159
Annual List of Preferred Providers 1301.160
Notification of Termination of Participation of Preferred Provider 1301.161
Retaliation Against Insured Prohibited 1301.162
Identification Card 1301.163
Applicability of Subchapter to Entities Contracting with Insurer 1301.164
Out-of-network Facility-based Providers 1301.165
Out-of-network Diagnostic Imaging Provider or Laboratory Service Provider 1301.166
Out-of-network Emergency Medical Services Provider 1301.201
Contracts with and Reimbursement for Nurse First Assistants 1301.202
Contracts with Hospitals 1301.0515
Acupuncturist Services 1301.0516
Chiropractic Services 1301.0521
Designation of Certain Podiatrists as Preferred Providers 1301.0522
Designation of Certain Optometrists, Therapeutic Optometrists, and Ophthalmologists as Preferred Providers 1301.00553
Maximum Travel Time and Distance Standards by Preferred Provider Type 1301.00554
Other Maximum Distance Standard Requirements 1301.00555
Maximum Appointment Wait Time Standards 1301.00565
Public Hearing on Network Adequacy Standards Waivers 1301.00566
Effect of Network Adequacy Standards Waiver on Balance Billing Prohibitions 1301.0625
Health Care Collaboratives 1301.0641
Contract Provisions Prohibiting Rejection of Batched Claims 1301.0642
Contract Provisions Allowing Certain Adverse Material Changes Prohibited 1301.1021
Receipt of Claim 1301.1051
Completion of Audit 1301.1052
Preferred Provider Appeal After Audit 1301.1053
Deadlines Not Extended 1301.1054
Requests for Additional Information 1301.1351
Posting of Preauthorization Requirements 1301.1352
Changes to Preauthorization Requirements 1301.1353
Remedy for Noncompliance 1301.1581
Information Concerning Exclusive Provider Benefit Plans 1301.1591
Preferred Provider Information on Internet
Green check means up to date. Up to date

Accessed:
Jun. 5, 2024

§ 1301.0055’s source at texas​.gov