1. (a) Requirements for health care managed care organizations (health care MCOs).

   1. (1) A health care 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. (2) A health care MCO must have pediatric and family practitioner PCPs in their network of providers in sufficient numbers to provide regular and preventive pediatric care and Texas Health Steps (THSteps) services to all eligible children enrolled in the service area.
   3. (3) A health care MCO must have PCPs and acute care hospitals available throughout the service area to ensure that no member must travel more than 30 miles from his or her residence to access the PCP, unless the Health and Human Services Commission (HHSC) has made an exception.
   4. (4) A health care MCO 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. (5) A health care MCO must ensure the reasonable availability and accessibility of specialists for all covered services requiring specialty care. Specialists must also be reasonably accessible to members in time, distance, cultural competency, and language.
   6. (6) A member of a health care MCO must not be required to travel in excess of 75 miles from his or her residence 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 (c) and (d) of this section.

2. (b) Requirements for dental managed care organizations (MCOs).

   1. (1) A dental MCO must provide a broad-based and accessible main dentist network within the service area to ensure member accessibility to providers in time, distance, cultural competency, and language.
   2. (2) A dental MCO must have main dentist providers in their network in sufficient numbers to provide regular and preventive dental care and THSteps services to all eligible children enrolled in the service area.
   3. (3) A dental MCO must have general dental providers throughout the service area to ensure that no member must travel more than 30 miles to access such providers in urban counties and 75 miles in rural counties, unless HHSC has made an exception.
   4. (4) A dental MCO must have general dental providers 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. (5) A dental MCO must ensure the reasonable availability and accessibility of dental specialists for all covered services. Dental specialists must also be reasonably accessible to members in time, distance, cultural competency, and language.
   6. (6) A member of a dental MCO must not be required to travel in excess of 75 miles from his or her residence to secure initial contact with referral dental specialists, unless HHSC has made an exception.
3. (c) Service or provider not available. If any service or provider is not available to a member within the mileage radius specified in subsections (a)(3), (a)(6), (b)(3), or (b)(6) of this section, the MCO must submit to HHSC for approval data that indicates covered health care services or dental services are not available to the member within the required distance.
4. (d) Service or provider outside the service area. The provisions in subsections (a)(3), (a)(6), (b)(3), and (b)(6) 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 that is available within the MCO service area. For health care MCOs, this can include treatment of cancer, burns, and cardiac diseases.

5. (e) Provider education and training.

   1. (1) A health care MCO must provide education and training to providers on the specific health and behavioral health problems and needs of members.
   2. (2) A dental MCO must provide education and training to providers on the specific dental health problems and needs of members.
   3. (3) All MCOs must provide education and training regarding the contract and rule requirements for accessibility and availability. MCOs and HHSC will cooperate and coordinate education and training activities for providers.

6. (f) Cultural competency plan. An MCO must develop a written cultural competency plan describing how the MCO will effectively provide health care services or dental 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 HHSC 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 HHSC for review and approval at intervals specified by HHSC.
7. (g) Verbal and physical barriers. An MCO must ensure that communication and physical access barriers do not deter members' timely access to health care services or dental services. The MCO must provide information in appropriate communication formats, including formats accessible to people with disabilities.
8. (h) Significant traditional providers. An MCO must not exclude Significant Traditional Providers from its network for a period of time and under conditions determined by HHSC and specified in the contract.
9. (i) Provider manual. An MCO must develop a written provider manual 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; amended to be effective August 10, 2005, 30 TexReg 4466; amended to be effective September 1, 2006, 31 TexReg 6629; amended to be effective March 1, 2012, 37 TexReg 1283.