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Texas Statutes (Last Updated: January 4, 2014) |
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INSURANCE CODE |
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Title 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES |
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Subtitle D. PROVIDER PLANS |
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Chapter 1305. WORKERS' COMPENSATION HEALTH CARE NETWORKS |
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Subchapter G. PROVISION OF SERVICES BY NETWORK; QUALITY IMPROVEMENT PROGRAM |
Sec. 1305.302. ACCESSIBILITY AND AVAILABILITY REQUIREMENTS
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(a) All services specified by this section must be provided by a provider who holds an appropriate license, unless the provider is exempt from license requirements.
(b) The network shall ensure that the network's provider panel includes an adequate number of treating doctors and specialists, who must be available and accessible to employees 24 hours a day, seven days a week, within the network's service area. A network must include sufficient numbers and types of health care providers to ensure choice, access, and quality of care to injured employees. An adequate number of the treating doctors and specialists must have admitting privileges at one or more network hospitals located within the network's service area to ensure that any necessary hospital admissions are made.
(c) Hospital services must be available and accessible 24 hours a day, seven days a week, within the network's service area. The network shall provide for the necessary hospital services by contracting with general, special, and psychiatric hospitals.
(d) Physical and occupational therapy services and chiropractic services must be available and accessible within the network's service area.
(e) Emergency care must be available and accessible 24 hours a day, seven days a week, without restrictions as to where the services are rendered.
(f) Except for emergencies, a network shall arrange for services, including referrals to specialists, to be accessible to employees on a timely basis on request, but not later than the last day of the third week after the date of the request.
(g) Each network shall provide that network services are sufficiently accessible and available as necessary to ensure that the distance from any point in the network's service area to a point of service by a treating doctor or general hospital is not greater than 30 miles in nonrural areas and 60 miles in rural areas and that the distance from any point in the network's service area to a point of service by a specialist or specialty hospital is not greater than 75 miles in nonrural areas and 75 miles in rural areas. For portions of the service area in which the network identifies noncompliance with this subsection, the network must file an access plan with the department in accordance with Subsection (h).
(h) The network shall submit an access plan, as required by commissioner rules, to the department for approval at least 30 days before implementation of the plan if any health care service or a network provider is not available to an employee within the distance specified by Subsection (g) because:
(1) providers are not located within that distance;
(2) the network is unable to obtain provider contracts after good faith attempts; or
(3) providers meeting the network's minimum quality of care and credentialing requirements are not located within that distance.
(i) The network may make arrangements with providers outside the service area to enable employees to receive a skill or specialty not available within the network service area.
(j) The network may not be required to expand services outside the network's service area to accommodate employees who live outside the service area.