1. (a) An enrollee shall not be required to:

   1. (1) travel in excess of 30 miles from the site of eligibility to reach a primary care physician and general hospital care except as provided in subsections (b) and (c) of this section;
   2. (2) travel in excess of 75 miles from the site of eligibility to secure contact with referral specialists, specialty hospitals, psychiatric hospitals, diagnostic and therapeutic services, and single or limited service health care physicians or providers except as provided in subsections (b) and (c) of this section;
   3. (3) for purposes of this subsection, "site of eligibility" refers to the location which makes the subscriber eligible for coverage.

2. (b) If any covered health care service or a participating physician and provider is not available to an enrollee within the mileage radii specified in subsection (a)(1) and (2) of this section because physicians and providers are not located within such mileage radii, or if the HMO is unable to obtain contracts after good faith attempts, or physicians and providers meeting the minimum quality of care and credentialing requirements of the HMO are not located within the mileage radii, the HMO shall submit a plan to the department for approval, at least 30 days before implementation. The plan shall include the following:

   1. (1) the geographic area identified by county, city, ZIP code, mileage, or other identifying data in which services and/or physicians and providers are not available;
   2. (2) for each geographic area identified as not having covered health care services and/or physicians or providers available, the reason or reasons that covered health care services and/or physicians and providers cannot be made available;
   3. (3) a map, with key and scale, which identifies the areas in which such covered health care services and/or physicians and providers are not available;
   4. (4) the HMO's general plan for making covered health care services and/or physicians and providers available to enrollees in each geographic area identified;
   5. (5) the names and addresses of the participating physicians and providers and a listing of the covered health care services to be provided through the HMO delivery network to meet the medical needs of the enrollees covered under the HMO's general plan required under paragraph (4) of this subsection;
   6. (6) the names and address of other physicians and providers and a listing of the specialties for any other health care services or physicians and providers to be made available in the geographic area in addition to those physicians and providers participating in the HMO delivery network listed under paragraph (5) of this subsection;
   7. (7) a general description of the day to day procedures to be followed by the HMO to assure that primary care physicians, general hospitals, referral specialists, special hospitals, psychiatric hospitals, diagnostic and therapeutic services, or single or limited health care service providers and all other mandated health care services are made available and accessible to enrollees in the geographic areas identified as being areas in which such covered health care services and/or physicians and providers are not available and accessible, and any plans of the HMO for attempting to develop an HMO delivery network through which covered health care services are available and accessible to enrollees in these geographic areas in the future; and
   8. (8) any other information which is necessary to assess the HMO's plan.
3. (c) The HMO is not precluded from making arrangements with physicians or providers outside the service area for enrollees to receive a higher level of skill or specialty than the level which is available within the HMO service area such as, but not limited to, treatment of cancer, burns, and cardiac diseases.
4. (d) The HMO shall require the HMO physicians and other providers of care who employ physician assistants, advanced practice nurses, dental hygienists and individuals other than physicians to assess the health care needs of HMO enrollees to have written policies which are implemented and enforced and describe the duties of all such providers in accordance with statutory requirements for licensure, delegation, collaboration, and supervision as appropriate.
5. (e) The HMO shall systematically and regularly verify that health care services furnished by physicians and providers of care such as dentists and physical therapists are available and accessible to enrollees without unreasonable periods of delay.
6. (f) The HMO shall develop and maintain a statistical reporting system which allows for compiling, developing, evaluating, and reporting statistics relating to the cost of operation, the pattern of utilization of its services, and the availability and accessibility of it services.
7. (g) Each health benefit plan delivered or issued for delivery by an HMO must include an HMO delivery network which is adequate and complies with the Insurance Code Article 20A.05(a)(1).
8. (h) The HMO shall not be required to expand services outside its service area to accommodate enrollees who live outside the service area, but work within the service area.
9. (i) Each evidence of coverage or certificate delivered or issued for delivery by an HMO may provide enrollees the option to access covered health care services through a telehealth service or a telemedicine medical service.
10. (j) Before providing telehealth services or telemedicine medical services to an enrollee, an HMO shall provide the enrollee with the option to select a physician or provider within the HMO delivery network to provide the covered health care services, or to elect to receive telehealth services or telemedicine medical services.
11. (k) In order to provide covered health care services to any enrollee by a telehealth service or a telemedicine medical service, an HMO shall satisfy the criteria specified under subsection (a) of this section.

Source Note:The provisions of this §11.1607 adopted to be effective November 2, 1998, 23 TexReg 11347; amended to be effective July 31, 2002, 27 TexReg 6701.