Relating to network adequacy standards for preferred provider benefit plans.
relating to network adequacy standards for preferred provider
benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1301.0055, Insurance Code, is amended by
amending Subsections (a) and (b) and adding Subsection (d) to read
as follows:
(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; and
(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 and[,] 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 at least 75 percent
of [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;
(3) [(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 at least 75 percent of [all]
insureds are able to receive covered benefits, including access to
clinical trials covered by the health benefit plan, at that
preferred location;
(4) [(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;
(5) [(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;
(6) [(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;
(7) [(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;
(8) [(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;
(9) [(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;
(10) [(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
(11) [(12)] require sufficient numbers and classes of
preferred providers to ensure choice, access, and quality of care
across the insurer’s designated service area.
(d) For the purposes of this section, a preferred provider
within the time and distance requirements of Section 1301.00553 is
considered part of the network adequacy calculation, regardless of
whether the provider’s office is located in a different county than
the insured or outside the insurer’s service area.
SECTION 2. Sections 1301.00553(c), (d), (e), (f), and (g),
Insurance Code, are amended to read as follows:
(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:
| Time | Distance |
| Allergy and Immunology | 40 [30] | 20 [15] |
| Cardiology | 30 [20] | 15 [10] |
| Cardiothoracic Surgery | 40 [30] | 20 [15] |
| Dermatology | 30 [20] | 15 [10] |
| Emergency Medicine | 30 [20] | 15 [10] |
| Endocrinology | 40 [30] | 20 [15] |
| Ear, Nose, and Throat/Otolaryngology | 40 [30] | 20 [15] |
| Gastroenterology | 30 [20] | 15 [10] |
| General Surgery | 30 [20] | 15 [10] |
| Gynecology and Obstetrics | 20 [10] | 10 [5] |
| Infectious Diseases | 40 [30] | 20 [15] |
| Nephrology | 40 [30] | 20 [15] |
| Neurology | 30 [20] | 15 [10] |
| Neurosurgery | 40 [30] | 20 [15] |
| Oncology: Medical, Surgical | 30 [20] | 15 [10] |
| Oncology: Radiation | 40 [30] | 20 [15] |
| Ophthalmology | 30 [20] | 15 [10] |
| Orthopedic Surgery | 30 [20] | 15 [10] |
| Physical Medicine and Rehabilitation | 40 [30] | 20 [15] |
| Plastic Surgery | 40 [30] | 20 [15] |
| Primary Care: Adults | 20 [10] | 10 [5] |
| Primary Care: Pediatric | 20 [10] | 10 [5] |
| Psychiatry | 30 [20] | 15 [10] |
| Pulmonology | 30 [20] | 15 [10] |
| Rheumatology | 40 [30] | 20 [15] |
| Urology | 30 [20] | 15 [10] |
| Vascular Surgery | 40 [30] | 20 [15] |
(2) for health care practitioners in the following
disciplines:
| Time | Distance |
| Chiropractic | 40 [30] | 20 [15] |
| Occupational Therapy | 30 [20] | 15 [10] |
| Physical Therapy | 30 [20] | 15 [10] |
| Podiatry | 30 [20] | 15 [10] |
| Speech Therapy | 30 [20] | 15 [10] |
(3) for the following types of institutional
providers:
| Time | Distance |
| Acute Inpatient Hospitals (Emergency Services Available 24/7) | 30 [20] | 15 [10] |
| Acute Inpatient Hospitals (Emergency Services Available 24/7) | 30 [20] | 15 [10] |
| Cardiac Catheterization Services | 40 [30] | 20 [15] |
| Cardiac Surgery Program | 40 [30] | 20 [15] |
| Critical Care Services: Intensive Care Units | 30 [20] | 15 [10] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 30 [20] | 15 [10] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 30 [20] | 15 [10] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 30 [20] | 15 [10] |
| Inpatient or Residential Behavioral Health Facility Services | 40 [30] | 20 [15] |
| Inpatient or Residential Behavioral Health Facility Services | 40 [30] | 20 [15] |
| Mammography | 30 [20] | 15 [10] |
| Outpatient Infusion/Chemotherapy | 30 [20] | 15 [10] |
| Skilled Nursing Facilities | 30 [20] | 15 [10] |
| Surgical Services (Outpatient or Ambulatory Surgical Center) | 30 [20] | 15 [10] |
| Surgical Services (Outpatient or Ambulatory Surgical Center) | 30 [20] | 15 [10] |
(4) for the following settings:
| Time | Distance |
| Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) | 20 [10] | 10 [5] |
| Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) | 20 [10] | 10 [5] |
| Urgent Care | 30 [20] | 15 [10] |
(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:
| Time | Distance |
| Allergy and Immunology | 60 [45] | 40 [30] |
| Cardiology | 45 [30] | 30 [20] |
| Cardiothoracic Surgery | 75 [60] | 50 [40] |
| Dermatology | 60 [45] | 40 [30] |
| Emergency Medicine | 60 [45] | 40 [30] |
| Endocrinology | 75 [60] | 50 [40] |
| Ear, Nose, and Throat/Otolaryngology | 60 [45] | 40 [30] |
| Gastroenterology | 60 [45] | 40 [30] |
| General Surgery | 45 [30] | 30 [20] |
| Gynecology and Obstetrics | 30 [15] | 20 [10] |
| Infectious Diseases | 75 [60] | 50 [40] |
| Nephrology | 60 [45] | 40 [30] |
| Neurology | 60 [45] | 40 [30] |
| Neurosurgery | 75 [60] | 50 [40] |
| Oncology: Medical, Surgical | 60 [45] | 40 [30] |
| Oncology: Radiation | 75 [60] | 50 [40] |
| Ophthalmology | 45 [30] | 30 [20] |
| Orthopedic Surgery | 45 [30] | 30 [20] |
| Physical Medicine and Rehabilitation | 60 [45] | 40 [30] |
| Plastic Surgery | 75 [60] | 50 [40] |
| Primary Care: Adults | 30 [15] | 20 [10] |
| Primary Care: Pediatric | 30 [15] | 20 [10] |
| Psychiatry | 60 [45] | 40 [30] |
| Pulmonology | 60 [45] | 40 [30] |
| Rheumatology | 75 [60] | 50 [40] |
| Urology | 60 [45] | 40 [30] |
| Vascular Surgery | 75 [60] | 50 [40] |
(2) for health care practitioners in the following
disciplines:
| Time | Distance |
| Chiropractic | 60 [45] | 40 [30] |
| Occupational Therapy | 60 [45] | 40 [30] |
| Physical Therapy | 60 [45] | 40 [30] |
| Podiatry | 60 [45] | 40 [30] |
| Speech Therapy | 60 [45] | 40 [30] |
(3) for the following types of institutional
providers:
| Time | Distance |
| Acute Inpatient Hospitals (Emergency Services Available 24/7) | 60 [45] | 40 [30] |
| Acute Inpatient Hospitals (Emergency Services Available 24/7) | 60 [45] | 40 [30] |
| Cardiac Catheterization Services | 75 [60] | 50 [40] |
| Cardiac Surgery Program | 75 [60] | 50 [40] |
| Critical Care Services: Intensive Care Units | 60 [45] | 40 [30] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 60 [45] | 40 [30] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 60 [45] | 40 [30] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 60 [45] | 40 [30] |
| Inpatient or Residential Behavioral Health Facility Services | 85 [70] | 55 [45] |
| Inpatient or Residential Behavioral Health Facility Services | 85 [70] | 55 [45] |
| Mammography | 60 [45] | 40 [30] |
| Outpatient Infusion/Chemotherapy | 60 [45] | 40 [30] |
| Skilled Nursing Facilities | 60 [45] | 40 [30] |
| Surgical Services (Outpatient or Ambulatory Surgical Center) | 60 [45] | 40 [30] |
| Surgical Services (Outpatient or Ambulatory Surgical Center) | 60 [45] | 40 [30] |
(4) for the following settings:
| Time | Distance |
| Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) | 30 [15] | 20 [10] |
| Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) | 30 [15] | 20 [10] |
| Urgent Care | 60 [45] | 40 [30] |
(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:
| Time | Distance |
| Allergy and Immunology | 110 [80] | 80 [60] |
| Cardiology | 80 [50] | 55 [35] |
| Cardiothoracic Surgery | 130 [100] | 95 [75] |
| Dermatology | 90 [60] | 65 [45] |
| Emergency Medicine | 110 [80] | 80 [60] |
| Endocrinology | 130 [100] | 95 [75] |
| Ear, Nose, and Throat/Otolaryngology | 110 [80] | 80 [60] |
| Gastroenterology | 90 [60] | 65 [45] |
| General Surgery | 80 [50] | 55 [35] |
| Gynecology and Obstetrics | 60 [30] | 40 [20] |
| Infectious Diseases | 130 [100] | 95 [75] |
| Nephrology | 110 [80] | 80 [60] |
| Neurology | 90 [60] | 65 [45] |
| Neurosurgery | 130 [100] | 95 [75] |
| Oncology: Medical, Surgical | 90 [60] | 65 [45] |
| Oncology: Radiation | 130 [100] | 95 [75] |
| Ophthalmology | 80 [50] | 55 [35] |
| Orthopedic Surgery | 80 [50] | 55 [35] |
| Physical Medicine and Rehabilitation | 110 [80] | 80 [60] |
| Plastic Surgery | 130 [100] | 95 [75] |
| Primary Care: Adults | 60 [30] | 40 [20] |
| Primary Care: Pediatric | 60 [30] | 40 [20] |
| Psychiatry | 90 [60] | 65 [45] |
| Pulmonology | 90 [60] | 65 [45] |
| Rheumatology | 130 [100] | 95 [75] |
| Urology | 90 [60] | 65 [45] |
| Vascular Surgery | 130 [100] | 95 [75] |
(2) for health care practitioners in the following
disciplines:
| Time | Distance |
| Chiropractic | 110 [80] | 80 [60] |
| Occupational Therapy | 110 [80] | 80 [60] |
| Physical Therapy | 110 [80] | 80 [60] |
| Podiatry | 90 [60] | 65 [45] |
| Speech Therapy | 110 [80] | 80 [60] |
(3) for the following types of institutional
providers:
| Time | Distance |
| Acute Inpatient Hospitals (Emergency Services Available 24/7) | 110 [80] | 80 [60] |
| Acute Inpatient Hospitals (Emergency Services Available 24/7) | 110 [80] | 80 [60] |
| Cardiac Catheterization Services | 190 [160] | 140 [120] |
| Cardiac Surgery Program | 190 [160] | 140 [120] |
| Critical Care Services: Intensive Care Units | 190 [160] | 140 [120] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 110 [80] | 80 [60] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 110 [80] | 80 [60] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 110 [80] | 80 [60] |
| Inpatient or Residential Behavioral Health Facility Services | 130 [100] | 95 [75] |
| Inpatient or Residential Behavioral Health Facility Services | 130 [100] | 95 [75] |
| Mammography | 110 [80] | 80 [60] |
| Outpatient Infusion/Chemotherapy | 110 [80] | 80 [60] |
| Skilled Nursing Facilities | 110 [80] | 80 [60] |
| Surgical Services (Outpatient or Ambulatory Surgical Center) | 110 [80] | 80 [60] |
| Surgical Services (Outpatient or Ambulatory Surgical Center) | 110 [80] | 80 [60] |
(4) for the following settings:
| Time | Distance |
| Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) | 60 [30] | 40 [20] |
| Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) | 60 [30] | 40 [20] |
| Urgent Care | 110 [80] | 80 [60] |
(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:
| Time | Distance |
| Allergy and Immunology | 120 [90] | 95 [75] |
| Cardiology | 105 [75] | 80 [60] |
| Cardiothoracic Surgery | 140 [110] | 110 [90] |
| Dermatology | 105 [75] | 80 [60] |
| Emergency Medicine | 105 [75] | 80 [60] |
| Endocrinology | 140 [110] | 110 [90] |
| Ear, Nose, and Throat/Otolaryngology | 120 [90] | 95 [75] |
| Gastroenterology | 105 [75] | 80 [60] |
| General Surgery | 105 [75] | 80 [60] |
| Gynecology and Obstetrics | 70 [40] | 50 [30] |
| Infectious Diseases | 140 [110] | 110 [90] |
| Nephrology | 120 [90] | 95 [75] |
| Neurology | 105 [75] | 80 [60] |
| Neurosurgery | 140 [110] | 110 [90] |
| Oncology: Medical, Surgical | 105 [75] | 80 [60] |
| Oncology: Radiation | 140 [110] | 110 [90] |
| Ophthalmology | 105 [75] | 80 [60] |
| Orthopedic Surgery | 105 [75] | 80 [60] |
| Physical Medicine and Rehabilitation | 120 [90] | 95 [75] |
| Plastic Surgery | 140 [110] | 110 [90] |
| Primary Care: Adults | 70 [40] | 50 [30] |
| Primary Care: Pediatric | 70 [40] | 50 [30] |
| Psychiatry | 105 [75] | 80 [60] |
| Pulmonology | 105 [75] | 80 [60] |
| Rheumatology | 140 [110] | 110 [90] |
| Urology | 105 [75] | 80 [60] |
| Vascular Surgery | 140 [110] | 110 [90] |
(2) for health care practitioners in the following
disciplines:
| Time | Distance |
| Chiropractic | 120 [90] | 95 [75] |
| Occupational Therapy | 105 [75] | 80 [60] |
| Physical Therapy | 105 [75] | 80 [60] |
| Podiatry | 105 [75] | 80 [60] |
| Speech Therapy | 105 [75] | 80 [60] |
(3) for the following types of institutional
providers:
| Time | Distance |
| Acute Inpatient Hospitals (Emergency Services Available 24/7) | 105 [75] | 80 [60] |
| Acute Inpatient Hospitals (Emergency Services Available 24/7) | 105 [75] | 80 [60] |
| Cardiac Catheterization Services | 175 [145] | 140 [120] |
| Cardiac Surgery Program | 175 [145] | 140 [120] |
| Critical Care Services: Intensive Care Units | 175 [145] | 140 [120] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 105 [75] | 80 [60] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 105 [75] | 80 [60] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 105 [75] | 80 [60] |
| Inpatient or Residential Behavioral Health Facility Services | 120 [90] | 95 [75] |
| Inpatient or Residential Behavioral Health Facility Services | 120 [90] | 95 [75] |
| Mammography | 105 [75] | 80 [60] |
| Outpatient Infusion/Chemotherapy | 105 [75] | 80 [60] |
| Skilled Nursing Facilities | 105 [75] | 80 [60] |
| Surgical Services (Outpatient or Ambulatory Surgical Center) | 105 [75] | 80 [60] |
| Surgical Services (Outpatient or Ambulatory Surgical Center) | 105 [75] | 80 [60] |
(4) for the following settings:
| Time | Distance |
| Outpatient Clinical Behavioral |
| Health (Licensed, Accredited, or Certified) | 70 [40] | 50 [30] |
| Urgent Care | 105 [75] | 80 [60] |
(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:
| Time | Distance |
| Allergy and Immunology | 155 [125] | 140 [110] |
| Cardiology | 125 [95] | 115 [85] |
| Cardiothoracic Surgery | 175 [145] | 160 [130] |
| Dermatology | 140 [110] | 130 [100] |
| Emergency Medicine | 140 [110] | 130 [100] |
| Endocrinology | 175 [145] | 160 [130] |
| Ear, Nose, and Throat/Otolaryngology | 155 [125] | 140 [110] |
| Gastroenterology | 140 [110] | 130 [100] |
| General Surgery | 125 [95] | 115 [85] |
| Gynecology and Obstetrics | 100 [70] | 90 [60] |
| Infectious Diseases | 175 [145] | 160 [130] |
| Nephrology | 155 [125] | 140 [110] |
| Neurology | 140 [110] | 130 [100] |
| Neurosurgery | 175 [145] | 160 [130] |
| Oncology: Medical, Surgical | 140 [110] | 130 [100] |
| Oncology: Radiation | 175 [145] | 160 [130] |
| Ophthalmology | 125 [95] | 115 [85] |
| Orthopedic Surgery | 125 [95] | 115 [85] |
| Physical Medicine and Rehabilitation | 155 [125] | 140 [110] |
| Plastic Surgery | 175 [145] | 160 [130] |
| Primary Care: Adults | 100 [70] | 90 [60] |
| Primary Care: Pediatric | 100 [70] | 90 [60] |
| Psychiatry | 140 [110] | 130 [100] |
| Pulmonology | 140 [110] | 130 [100] |
| Rheumatology | 175 [145] | 160 [130] |
| Urology | 140 [110] | 130 [100] |
| Vascular Surgery | 175 [145] | 160 [130] |
(2) for health care practitioners in the following
disciplines:
| Time | Distance |
| Chiropractic | 155 [125] | 140 [110] |
| Occupational Therapy | 140 [110] | 130 [100] |
| Physical Therapy | 140 [110] | 130 [100] |
| Podiatry | 140 [110] | 130 [100] |
| Speech Therapy | 140 [110] | 130 [100] |
(3) for the following institutional providers:
| Time | Distance |
| Acute Inpatient Hospitals (Emergency Services Available 24/7) | 140 [110] | 130 [100] |
| Acute Inpatient Hospitals (Emergency Services Available 24/7) | 140 [110] | 130 [100] |
| Cardiac Catheterization Services | 185 [155] | 170 [140] |
| Cardiac Surgery Program | 185 [155] | 170 [140] |
| Critical Care Services: Intensive Care Units | 185 [155] | 170 [140] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 140 [110] | 130 [100] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 140 [110] | 130 [100] |
| Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) | 140 [110] | 130 [100] |
| Inpatient or Residential Behavioral Health Facility Services | 185 [155] | 170 [140] |
| Inpatient or Residential Behavioral Health Facility Services | 185 [155] | 170 [140] |
| Mammography | 140 [110] | 130 [100] |
| Outpatient Infusion/Chemotherapy | 140 [110] | 130 [100] |
| Skilled Nursing Facilities | 125 [95] | 115 [85] |
| Surgical Services (Outpatient or Ambulatory Surgical Center) | 140 [110] | 130 [100] |
| Surgical Services (Outpatient or Ambulatory Surgical Center) | 140 [110] | 130 [100] |
(4) for the following settings:
| Time | Distance |
| Outpatient Clinical Behavioral |
| Health (Licensed, Accredited, or Certified) | 100 [70] | 90 [60] |
| Urgent Care | 140 [110] | 130 [100] |
SECTION 3. Section 1301.0056(a-1), Insurance Code, is
amended to read as follows:
(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.
SECTION 4. Section 1301.009(b), Insurance Code, is amended
to read as follows:
(b) The report shall:
(1) be verified by at least two principal officers;
(2) be in a form prescribed by the commissioner; and
(3) include:
(A) a financial statement of the insurer,
including its balance sheet and receipts and disbursements for the
preceding calendar year, certified by an independent public
accountant;
(B) the number of individuals enrolled during the
preceding calendar year, the number of enrollees as of the end of
that year, and the number of enrollments terminated during that
year; and
(C) a statement of:
(i) an evaluation of enrollee satisfaction;
(ii) an evaluation of quality of care;
(iii) coverage areas;
(iv) accreditation status;
(v) premium costs;
(vi) plan costs;
(vii) premium increases;
(viii) the range of benefits provided;
(ix) copayments and deductibles;
(x) the accuracy and speed of claims
payment by the insurer for the plan;
(xi) the credentials of physicians who are
preferred providers;
(xii) the number of preferred providers;
(xiii) any waiver requests made and waivers
of network adequacy standards granted under Section 1301.0055
[1301.00565];
(xiv) any material deviation from network
adequacy standards reported to the department under Section
1301.0055; and
(xv) any corrective actions, sanctions, or
penalties assessed against the insurer by the department for
deficiencies related to the preferred provider benefit plan.
SECTION 5. Sections 1301.00555 and 1301.00565, Insurance
Code, are repealed.
SECTION 6. The changes in law made by this Act apply only to
an insurance policy that is delivered, issued for delivery, or
renewed on or after January 1, 2026. A policy delivered, issued
for delivery, or renewed before January 1, 2026, is governed by the
law as it existed immediately before the effective date of this Act,
and that law is continued in effect for that purpose.
SECTION 7. This Act takes effect September 1, 2025.
