Exclusive Provider Benefit Plan (EPBP) and Preferred Provider Benefit Plan (PPBP) Networks
A Texas Life/Health insurer may elect to offer an EPBP in accordance with Texas Insurance Code (TIC) Chapter 1301, and rules in 28 Texas Administrative Code (TAC) Chapter 3, Subchapter X.The Texas Department of Insurance (TDI) regulates EPBP networks that Texas Life/Health insurers use to provide covered benefits to their EPBP enrollees. Before offering an EPBP in Texas, a Life/Health insurer must:
- complete the Application for Approval of Exclusive Provider Benefit Plan, (TDI form LHL658), and submit to TDI for approval;
- undergo a qualifying examination, during which department staff may review the insurer's quality improvement program, utilization management program, the EPBP network configuration, the insurer's EPBP credentialing files, written materials for prospective EPBP enrollees, and the insurer's categorized complaint log; and
- obtain approval of the policy and certificate of coverage that the insurer will issue to its EPBP enrollees.
The insurer's EPBP network must meet all applicable provider availability and accessibility requirements in 28 TAC §3.3704. If the insurer's EPBP network does not meet all the requirements, the insurer must apply for a waiver of the requirements from TDI, and the insurer must file an EPBP network access plan with TDI for approval. The PPBP and EPBP Annual Report, Waiver Request and Access Plan Checklist, (TDI form FIN543) describes the requirements that apply to an insurer's EPBP network access plan.
A Texas Life/Health insurer may elect to offer a PPBP in accordance with TIC Chapter 1301, and rules in 28 TAC Chapter 3, Subchapter X.
TDI regulates PPBP networks that Texas Life/Health insurers use to provide covered benefits to their PPBP enrollees. Before offering a PPBP in Texas, a Life/Health insurer must:
- enter into a contract with a preferred provider organization; and
- obtain approval of a PPBP policy and certificate of coverage from TDI.
Annual Network Adequacy Report
On or before April 1 of each year and before marketing any PPBP or an EPBP in a new service area, a Texas Life/Health insurer that TDI authorized to offer a PPBP or an EPBP must file a network adequacy report with TDI. The insurer's annual network adequacy report must include all of the information described in 28 TAC §3.3709. If an insurer's PPBP or EPBP network(s) does not meet all the applicable network adequacy requirements, the insurer must submit a network adequacy waiver request and a network access plan to TDI for approval. The PPBP and EPBP Annual Report, Waiver Request and access Plan Checklist (TDI form FIN543) can be accessed from TDI's website at http://www.tdi.texas.gov/forms/finmcqa/FIN543.pdf
PPBP and EPBP Annual Report, Waiver Request & Access Plan Checklist- (TDI form FIN543) describes the network adequacy requirements that apply to an insurer's PPBP and EPBP networks. This form should be submitted to TDI to file your Annual Network Adequacy Report and Waiver Request and Network Access Plans approvals.
TDI is required to post information relevant to the grant of a waiver on its website. That information can be accessed at http://www.tdi.texas.gov/hmo/mcqa/networkadqwaivr.html.
For more information, contact:
Last updated: 01/25/2016