1. (a) Managed care organizations (MCO) must provide a broad-based and accessible primary care provider (PCP) network within the service area to ensure member accessibility to providers in time, distance, cultural competency and language.
2. (b) MCOs shall have pediatric and family practitioner PCPs in their network of providers in sufficient numbers to provide regular and preventive pediatric care and THSteps services to all eligible children enrolled in the service area.
3. (c) MCOs shall have PCPs available throughout the service area to ensure that no member must travel more than 30 miles to access the PCP, unless an exception has been made by the department.
4. (d) MCOs shall have PCPs in sufficient numbers to ensure that PCPs do not exceed the maximum allowable enrolled members, that no member must wait an unreasonable amount of time for an appointment, and that no member must wait an unreasonable amount of time to be seen at their appointed time.
5. (e) MCOs shall ensure the reasonable availability and accessibility of specialists in all areas of medical and behavioral health practice. Specialists must also be reasonably accessible to members in time, distance, cultural competency and language.
6. (f) A member shall not be required to travel in excess of 75 miles to secure initial contact with referral specialists; special hospitals; psychiatric hospitals; diagnostic and therapeutic services; and single service health care physicians, dentists or providers except as provided in subsections (g) and (h) of this section.
7. (g) If any service or provider is not available to a member within the mileage radius specified in subsection (f) of this section, the MCO shall submit to the department for approval health care utilization data which indicates a normal pattern for securing health care services within the service area.
8. (h) The provisions in subsection (f) of this section do not preclude an MCO from making arrangements with another source outside the service area for members to receive a higher level of skill or specialty than the level which is available within the MCO service area such as, but not limited to, treatment of cancer, burns, and cardiac diseases.
9. (i) MCOs shall provide education and training to providers on the specific health and behavioral health problems and needs of STAR Program members, and the contract and rule requirements for accessibility and availability. MCOs and the department shall cooperate and coordinate education and training activities for providers.

10. (j) MCOs shall develop a written cultural competency plan describing how the MCO will effectively provide health care services to members from varying cultures, races, ethnic backgrounds and religions to ensure those characteristics do not pose barriers to gaining access to needed services. As part of the requirement to develop the cultural competency plan, the MCO must at a minimum:

    1. (1) employ multi-cultural and multi-lingual staff;
    2. (2) make available interpreter services for members as necessary to ensure availability of effective communication regarding treatment, medical history or health education;
    3. (3) display to the department through the written plan a method for incorporating the plan into the MCO's policy-making process, administration, and daily practices; and
    4. (4) submit the written plan to the department for review and approval at intervals specified by the department.
11. (k) MCOs must ensure that communication or physical access barriers do not deter members' timely access to health care services. The MCOs shall provide information in appropriate communication formats, including formats accessible to people with disabilities.
12. (l) MCOs are prohibited from excluding significant traditional Medicaid providers from their network for a period of time and under conditions determined by the state and specified in the contract.
13. (m) MCOs shall develop written provider manuals clearly stating the policies and procedures adopted by the MCO to meet the provider's duties and obligations required by these and other agency rules and the contract.

Source Note:The provisions of this §353.411 adopted to be effective December 18, 1996, 21 TexReg 11822; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561.