A Texas life/health insurer may elect to offer a PPBP or EPBP network to provide covered benefits to their enrollees, in accordance with Texas Insurance Code Chapter 1301, and rules in 28 Texas Administrative Code (TAC) Chapter 3, Subchapter X. The Texas Department of Insurance (the department) regulates these networks.
An insurer's PPBP or EPBP network(s) must meet all applicable provider availability and accessibility requirements in 28 TAC Section 3.3704. If the network contains any gaps in service or coverage for enrollees in the contracted network, the insurer must file an access plan with the department for approval. The access plan ensures enrollees have access to all required services and that the network is adequate. The PPBP and EPBP, Annual Report, Waiver Request, and Access Plan Checklist (TDI form LHL706), describes the requirements that apply to an insurer's network access plan. See annual network adequacy report below for more information.
PPBP networks
Before offering a PPBP network in Texas, a life/health insurer must:
- enter into a contract with a preferred provider organization; and
- obtain the department's approval of a PPBP policy and certificate of coverage.
EPBP networks
Before offering an EPBP network in Texas, a life/health insurer must:
- submit to the department for approval the application for approval of exclusive provider benefit plan, (TDI form LHL658);
- 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 the department's approval of a EPBP policy and certificate of coverage.
Annual network adequacy report
On or before April 1 of each year and before marketing any PPBP or EPBP networks in a new service area, Texas life/health insurers must file a network adequacy report with the department. The insurer's annual network adequacy report must include all of the information described in 28 TAC Section 3.3709. If an insurer's PPBP or EPBP network(s) contain any gaps in service or coverage for enrollees in the contracted network, they must file an access plan with the department for approval. The access plan ensures enrollees have access to all required services and that the network is adequate. The PPBP and EPBP, Annual Report, Waiver Request, and Access Plan Checklist (TDI form LHL706) describes the network adequacy requirements that apply to PPBP and EPBP networks.
TDI is required to post information relevant to an approved access plan for network gaps in service or coverage for enrollees on its website. That information can be accessed at www.tdi.texas.gov/hmo/mcqa/networkadqacspln.html.