Section 10.80 - Accessibility and Availability Requirements(a) All services specified by this section must be provided by a provider who holds a current appropriate Texas license, unless the provider is exempt from license requirements.(b) The network must ensure that the network's provider panel includes: (1) an adequate number of contracted 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;(2) sufficient numbers and types of health care providers to ensure choice, access, and quality of care to injured employees;(3) an adequate number of treating doctors and specialists who have admitting privileges at one or more network hospitals located within the network's service area to make any necessary hospital admissions;(4) hospital services that are available and accessible 24 hours a day, seven days a week, within the network's service area. The network must provide for the necessary hospital services by contracting with general, special, and psychiatric hospitals, as applicable;(5) physical and occupational therapy services and chiropractic services that are available and accessible within the network's service area;(6) emergency care that is available and accessible 24 hours a day, seven days a week, without restrictions as to where the services are rendered; and(7) an adequate number of doctors who are qualified to provide maximum medical improvement and impairment rating services as required under Labor Code § 408.023, concerning List of Approved Doctors; Duties of Treating Doctors.(c) Except for emergencies, a network must arrange for services, including referrals to specialists, to be accessible to injured employees within the time appropriate to the circumstances and condition of the injured employee, but not later than 21 calendar days after the date of the original request.(d) Each network must 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: (1) 30 miles in nonrural areas; and(2) 60 miles in rural areas.(e) Each network must 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 specialist or specialty hospital is not greater than: (1) 75 miles in nonrural areas; and(2) 75 miles in rural areas.(f) For portions of the service area in which the network or department identifies noncompliance with this section, the network must file an access plan with 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 because: (1) providers are not located within the required distances;(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 the required distances.(g) The access plan required under subsection (f) of this section must include: (1) a description of the geographic area in which services or providers are not available, identified by county, city, ZIP code, mileage, or other identifying data;(2) a map, with key and scale, which identifies the areas in which such health care services or providers are not available;(3) documentation that demonstrates how the network determined that providers are not located within the required distances;(4) the network's general plan for making health care services and providers available to injured employees in each geographic area identified in the access plan, including:(A) the names, addresses, and specialties of the network providers and a listing of the services to be provided through the network that meet the health care needs of the employees; and(B) a network development and provider contracting plan through which health care services or providers will be made available and accessible to employees in these geographic areas in the future;(5) if a general hospital is not available in an approved nonrural county, or a general acute hospital is available in an approved nonrural area but refuses to contract with the network, lists of:(A) contracted providers who have admitting privileges in a general hospital in each approved nonrural area who may admit injured employees; and(B) alternative but contracted nonacute care facilities that can provide required acute hospital services to injured employees;(6) a list of the physicians, providers, and facilities within the relevant service area that the network attempted to contract with, identified by name and specialty or facility type, with:(A) a description of how and when the network last contacted each physician, provider, or facility; and(B) a description of the reason each physician, provider, or facility gave for declining to contract with the network; and(7) any other information necessary to allow the department to assess and approve the network's access plan.(h) The network may make arrangements with providers outside the service area to enable employees to receive skilled or specialty care not available within the network service area.(i) The network is not required to expand services outside the network's service area to accommodate employees who live outside the service area.28 Tex. Admin. Code § 10.80
The provisions of this §10.80 adopted to be effective December 5, 2005, 30 TexReg 8099; The provisions of this §10.80 adopted to be effective December 5, 2005, 30 TexReg 8099; Amended by Texas Register, Volume 47, Number 30, July 29, 2022, TexReg 4553, eff. 8/2/2022