1. (a) Health maintenance organizations (HMO) 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) HMOs must 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) HMOs must have PCPs and acute care hospitals 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 Commission.
4. (d) HMOs must have PCPs in sufficient numbers to ensure 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) HMOs must 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 must 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 HMO must submit to the Commission for approval health care utilization data that indicate 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 HMO from making arrangements with another source outside the service area for members to receive a higher level of skill or specialty than the level that is available within the HMO service area such as, but not limited to, treatment of cancer, burns, and cardiac diseases.
9. (i) HMOs must provide education and training to providers on the specific health and behavioral health problems and needs of Medicaid Managed Care Program members, and the contract and rule requirements for accessibility and availability. HMOs and the Commission shall cooperate and coordinate education and training activities for providers.

10. (j) HMOs must develop a written cultural competency plan describing how the HMO 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 HMO 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 HHSC through the written plan a method for incorporating the plan into the HMOs policy-making process, administration, and daily practices; and
    4. (4) submit the written plan to HHSC for review and approval at intervals specified by the department.
11. (k) HMOs must ensure that communication or physical access barriers do not deter members' timely access to health care services. The HMOs shall provide information in appropriate communication formats, including formats accessible to people with disabilities.
12. (l) HMOs are prohibited from excluding Significant Traditional Providers from their network for a period of time and under conditions determined by the state and specified in the contract.
13. (m) HMOs must develop written provider manuals clearly stating the policies and procedures adopted by the HMO 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; amended to be effective August 10, 2005, 30 TexReg 4466.