An Exclusive provider organization/Preferred provider organization (EPO/PPO) offers healthcare coverage through a specific pre-approved network of doctors, hospitals, and health care providers. 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 (TIC) Chapter 1301, and rules in 28 Texas Administrative Code (TAC) Chapter 3, Subchapter X. The Texas Department of Insurance (TDI or the department) regulates these networks.
House Bill 3359, 88th Legislature, 2023 added new health plan network adequacy standards for preferred provider and exclusive provider benefit plans. TDI published PPO Updates (88th) Rule Proposal (PDF) on December 8, 2023 for implementation of House Bill 3359 and several bills applicable to PPO or EPO plans. The PPO rule adoption (PDF) was submitted to the Texas Register. It published in the April 19, 2024, issue. Its effective date is April 25, 2024. The rule was posted online. The rules specify how insurers must demonstrate compliance with network adequacy requirements and how to request waivers if there is a network gap. The network adequacy reporting forms were also developed to meet the regulation of the new network adequacy standards.
Access the new EPO/PPO forms.
The PPO Updates (88th) (PDF) rule and the revisions included in the adoption order (PDF) were proposed under the following bills that were passed by the 88th Legislature in 2023:
- HB 3359 provides extensive network adequacy standards and requirements.
- HB 711 prohibits anticompetitive contracting provisions.
- HB 1647 provides protections for certain clinician-administered drugs.
- HB 1696 expands protections for optometrists and therapeutic optometrists when contracting with managed care plans.
- HB 2002 requires insurers to credit certain out-of-network payment amounts to the enrollee's deductible and maximum out-of-pocket amount.
- SB 1003 expands the facility-based provider types that must be specifically listed in provider directories, consistent with TDI's biennial recommendation.
- SB 2476 creates new payment standards and balance billing protections for ground ambulance services.
The rule was also proposed under SB 1264, which was passed by the 86th Legislature and prohibits balance billing for certain health benefit claims.
Insurers offering Preferred Provider Organization (PPO) and/or Exclusive Provider Organization (EPO) health plans are required to demonstrate that the plan network meets all Texas applicable provider availability and accessibility requirements in Texas Insurance Code 1301. Under Texas Insurance Code § 1301.0055, when a network does not meet these time and distance requirements and appointment wait times (2025) in a county for a specific provider specialty type, an insurer may apply for a waiver to operate within its service area with the identified network gaps. The commissioner of TDI may grant the waiver after consideration of relevant testimony and information following a virtual public hearing consistent with House Bill 3359. Health care providers and consumers can share related information, which TDI will consider when it decides whether to grant the waiver request.
PPBP & EPBP networks
Before offering a network in Texas, a life/health insurer must:
- Enter into a contract with a preferred or exclusive provider organization.
- Undergo a qualifying examination/review.
- Submit an application and supporting documentation as required by 28 TAC Chapter 3, Subchapter X, for review and approval by TDI’s program areas of:
- Accident and Health
- Managed Care Quality Assurance
- Market Conduct Examinations
- Obtain the department's approval of a policy and certificate of coverage.
Annual network adequacy report
May 1 filing deadline for 2024 annual PPO/EPO network adequacy reports - TDI issued a bulletin notifying insurers that it's suspending enforcement until May 1, 2024, of the deadline for insurers to file 2024 annual network adequacy reports required under 28 TAC Section 3.3709.
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 the network contains any gaps in service or coverage for enrollees in the contracted network, the insurer must file a waiver request and 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 commissioner of TDI may grant the waiver following a public hearing and consideration of relevant testimony and information. Anyone may attend the public hearing and offer testimony either in person or virtually.
EPO/PPO revised draft forms
The PPO rule adoption (PDF) includes descriptions of the revisions made to the previously posted versions of the draft forms.
Major medical (version 4.9.2024)
- Attempt to Contract (Excel)
- Annual Network Adequacy Report (Excel)
- Network Compliance and Waiver Request (Excel)
- Provider Listings (Excel)
Vision (version 4.9.2024)
- Attempt to Contract (Excel)
- Annual Network Adequacy Report (Excel)
- Network Compliance and Waiver Request (Excel)
- Provider Listings (Excel)