Baylor Scott & White Health Plan access plan Coverage

When Network Is Inadequate — Coverage & Access Rules

Network access and remedial actions

When required providers/services are not available within the mileage radii or cannot be contracted after good faith attempts, the plan implements its access procedures.

No participating provider available within required mileage radii or unable to contract after good faith attempts (per TAC S11.1607 and plan access processes).

Plan negotiates a Letter of Agreement or executes a Single-Case Agreement with an out-of-network provider to deliver the required service as in-network for the member.

Agreements include hold-harmless language prohibiting the provider from seeking reimbursement from the member for services covered under the agreement (including in event of plan non-payment or insolvency).

Network Issues Committee and plan leadership continually monitor network adequacy (monthly) and the contracting team pursues contracting or other network expansion efforts to address gaps.

Access plan (local access mechanisms) is used only when no providers are available to contract within the service area or credentialing is pending; it is not used in lieu of contracting.

When access plan actions are used, the plan documents reasons and remediation steps as required by TAC and internal governance.

Network inadequacy coverage procedures

Coverage when network inadequate

If a covered member cannot obtain a required specialty/service within the contracted network, the contracting team will research and identify an appropriate provider and begin the contracting process or negotiate a Single-Case Agreement/Letter of Agreement to provide the service as in-network.

Members provided services under negotiated agreements receive in-network benefit coverage; providers agree to hold-harmless members from billing related to plan non-payment, insolvency, or breach.

Access plans are applied only where no providers are available to contract locally; the plan will continue efforts to expand the network to reduce future reliance on waivers/access plans.

Contracting duties are not delegated; when credentialing is delegated to provider groups, a pre-delegation assessment is completed to ensure the group meets BSWHP regulatory standards.

Network inadequacy coverage criteria

When required specialties are not available in-network, BSWHP will secure in-network benefits via agreements and will not hold members financially responsible.

Condition: No in-network provider available for required specialty/service.

Action: Contracting team negotiates a Single-Case Agreement or Letter of Agreement with an out-of-network provider to provide the service at in-network benefit levels.

Requirement: Agreements include hold-harmless language preventing providers from seeking reimbursement from the member for services provided under the agreement.

If credentialing is delegated to a group, a pre-delegation assessment must be completed to ensure the group follows BSWHP regulatory standards.

Access plan may be used only when no providers are available to contract within the service area; it is not a substitute for contracting.

Coverage stance for services in areas with network inadequacy

When required provider specialty or service is not available in-network in a county, BSWHP will take steps to ensure member access and provide in-network benefits via agreements or contracting efforts.

If a member cannot obtain a required specialty/service in-network, the contracting team will identify an out-of-network provider and negotiate a Letter of Agreement or Single-Case Agreement to provide services as in-network.

These agreements include hold-harmless language to protect members from balance billing or provider recourse related to plan non-payment or insolvency.

The access plan is used only when no providers are available to contract locally and is not used in lieu of contracting; the plan takes steps to improve network adequacy to avoid recurring waivers.

Access plan operational criteria

When a required provider specialty or service is not available within the contracted network in an area, BSWHP will take the following actions to ensure member access and in-network benefits.

Contracting duties are generally not delegated; credentialing may be delegated to groups only after a pre-delegation assessment that confirms regulatory equivalence.

Access plan is a fallback used only when no providers are available to contract in the service area; it is not a substitute for contracting and does not generate claimed cost savings.

BSWHP negotiates Letters of Agreement or Single-Case Agreements with out-of-network providers to render services as in-network while continuing contracting efforts.

Provider directory practices (e.g., listing providers at multiple practice addresses) may reflect provider availability and are used to represent access appropriately.

Network inadequacy response and member coverage

When network inadequacy prevents member access to required specialty services, the plan will take steps to ensure in-network coverage via contracting or access plan as described below.

Step: If a member cannot access specialized services in-network, the contracting team will identify an appropriate out-of-network provider and initiate a Single-Case Agreement or Letter of Agreement to provide the service as in-network.

Condition: Single-Case Agreements/Letters of Agreement include hold-harmless language prohibiting providers from seeking reimbursement from members in the event of plan non-payment, insolvency, or breach.

Step: Access plan may be used only when no providers are available to contract within the service area; it is not a replacement for contracting.

Operation: Contracting duties are not delegated; credentialing may be delegated to groups that pass a pre-delegation assessment to ensure compliance with BSWHP standards.

Note: Provider directory may list the same provider at multiple practice addresses to reflect multiple practice locations or rotating coverage, supporting availability assessments.

Network inadequacy coverage criteria

Coverage stance when network inadequacy exists:

If a member cannot access a required specialty within the contracted network, BSWHP will seek a Single-Case Agreement or Letter of Agreement with an out-of-network provider to provide the service as in-network.

Providers under Single-Case Agreements/Letters of Agreement must include hold-harmless language preventing them from seeking reimbursement from the member for services rendered under the agreement.

The access plan is a fallback applied only when there are no available providers to contract within the service area and is not used instead of contracting; BSWHP reports no anticipated claims cost savings from using the access plan as a substitute.

BSWHP monitors network adequacy through leadership review and committees (e.g., Network Issues Committee) and pursues contracting and single-case agreements to address insufficiencies.

Access plan / single-case coverage criteria

Coverage stance and operational approach when network is inadequate:

Condition: Required provider specialty not available in the area.

Action: Negotiate a Letter of Agreement or Single-Case Agreement with an out-of-network provider so the member can receive services at in-network benefit levels.

Member protection: Agreements include hold-harmless language; members will not be billed for services covered under these agreements.

Process: Contracting team will identify and begin contracting with an out-of-network provider when a member cannot obtain specialized services within the contracted network.

Limitation: The access plan is used only when no providers are available and is not a substitute for contracting; consequently no anticipated claim cost savings result from access plan use in place of contracting.

Network inadequacy response

Coverage stance when network specialty is inadequate

Condition: Required provider specialty not available in-network for the member's area.

Action: Plan negotiates a Single-Case Agreement or Letter of Agreement with an out-of-network provider to ensure the member receives the required service at in-network benefit levels.

Access plan condition: Access plan is considered only when no providers are available to contract within the service area; it is not used in lieu of contracting.

Member protection: Hold-harmless language in agreements prevents providers from seeking reimbursement from the member for services provided under the agreement.

Access and contracting criteria

When a required provider specialty is not available in-network, BSWHP will take steps to ensure members receive authorized services at in-network benefit levels.

Condition: Required specialty not available in-network.

Action: Contract with an out-of-network provider via Letter of Agreement or Single-Case Agreement to provide the service at in-network benefit coverage.

Condition: If no providers are available to contract in the service area, the access plan may be used as a fallback; it is not a substitute for contracting.

Requirement: Single-Case Agreements include a hold-harmless clause preventing provider recourse against the member for reimbursement.

Credentialing: When a multi-location group requests credentialing delegation, a pre-delegation assessment is required to ensure the group meets BSWHP regulatory standards.

Access plan / single-case agreement coverage criteria

Coverage stance when network is inadequate:

1: When no in-network provider exists: If a member cannot obtain a required specialty/service within the contracted network in the member’s area, the contracting team identifies an out-of-network provider and negotiates a Single-Case Agreement or Letter of Agreement to render services as in-network for the member.

2: Provider reimbursement recourse: When a provider signs a Single-Case Agreement/Letter of Agreement, the provider agrees not to seek reimbursement from the member or persons acting on their behalf even if the plan fails to pay.

3: Use of access plan: Access plan is used only when no providers are available to contract within the service area; it is not used as a substitute for contracting and the plan will take steps to expand the network to avoid future waivers.

Access procedures and member protection

When required specialty or sufficient in-network providers are not available in a county, BSWHP will attempt to make services available by:

Research and identify an out-of-network provider to administer the required service and begin the contracting process (Single-Case Agreement/Letter of Agreement) to provide in-network benefit coverage.

Use the access plan only when no providers are available to contract within the service area; access plan is not used in lieu of contracting.

Ensure Single-Case Agreements/Letters of Agreement include hold-harmless language prohibiting providers from seeking reimbursement from members for services provided under the agreement.

Perform pre-delegation assessment before delegating credentialing to provider groups to ensure regulatory standards are met.

Continue oversight via the Network Issues Committee and business expansion strategies to address network gaps; document geographic scope and reasons for access actions as required.

Network inadequacy response

When a required specialty or service is not available in-network in a county, BSWHP will provide in-network benefits through agreements with out-of-network providers and pursue contracting to address network gaps.

BSWHP negotiates Letters of Agreement or Single-Case Agreements with out-of-network providers to ensure members receive in-network benefit coverage when network inadequacy prevents local access.

Contracting team will research and identify out-of-network providers and begin contracting when members cannot obtain specialized services within the contracted network.

Agreements include hold-harmless language to protect members from balance billing or provider recourse; the plan documents affected counties and specialties in the access plan.

Network inadequacy response criteria

When a required provider specialty or service is not available in the contracted network for a member, BSWHP actions include:

Action: Research and identify an out-of-network provider to administer the required service and begin contracting or negotiate a Single-Case Agreement/Letter of Agreement to provide in-network benefit coverage.

Condition: Access plan is used only when no providers are available to contract within the service area; it is not used in lieu of contracting and therefore produces no estimated claims cost savings.

Requirement: Single-Case Agreements/Letters of Agreement include hold-harmless language prohibiting providers from seeking reimbursement from members for services provided under the agreement.

Credentialing: Contracting duties are not delegated; credentialing may be delegated to groups with sufficient providers after a pre-delegation assessment to ensure regulatory standards are met.

Oversight: BSWHP evaluates network adequacy via the Network Issues Committee and pursues contracting/business expansion to reduce reliance on access plan waivers.

Coverage when network inadequate

Coverage via single-case agreements/Letters of Agreement is provided when the network lacks required provider specialties in a county or area.

When the network lacks required provider specialties in a county, BSWHP will negotiate Single-Case Agreements or Letters of Agreement with out-of-network providers to provide covered services at in-network benefit levels for affected members.

These arrangements include member protections (hold-harmless language) and are used only where no in-network providers are available to contract; contracting efforts continue concurrently.

Contracting & Operational Steps for Providers / Contracting Team

Note

Access plan usage

ACCESS PLAN: Baylor Scott & White Health Plan (BSWHP) maintains active policies and procedures to ensure members can access authorized services as in‑network when the network lacks sufficient providers in a county or specialty. When a network gap is identified, BSWHP will: 1) research and identify an appropriate provider; 2) attempt to contract with an in‑network provider; and 3) when contracting the provider is not immediately available or feasible, execute a Single‑Case Agreement (SCA) or Letter of Agreement (LOA) with an out‑of‑network provider so the member receives in‑network benefit coverage. Members receiving services under an SCA/LOA will not be balance‑billed for covered services.

Used when no available in‑network provider exists for the required specialty or service
Contracting team initiates Single‑Case Agreement or Letter of Agreement as needed
Network Issues Committee monitors access and network adequacy and informs contracting actions

Prior Authorization

Single‑case agreements / Letters of Agreement

Single‑case agreements and Letters of Agreement are used to address temporary or localized network inadequacies (for example, in rural counties or when a specialty is not available in sufficient numbers). The contracting team immediately researches provider availability and begins the contracting process. When an in‑network contract cannot be completed in time to meet a member’s clinical need, BSWHP will execute an SCA or LOA to allow in‑network benefits for services provided.

Applies to any specialty/service identified as unavailable within the service area
Used to ensure member access while longer‑term contracting efforts continue

Denial Risk

Hold‑harmless in agreements

Content of SCA/LOA: BSWHP includes hold‑harmless language in its SCAs and LOAs to protect members. Typical hold‑harmless wording specifies that the provider agrees it will not seek reimbursement from the member for services covered under the agreement, and shall not bill, collect from, or have recourse against the member for payment of covered services even in events such as non‑payment, insolvency, or breach by BSWHP.

Provider agrees no recourse against member for services provided under SCA/LOA
Protects members from balance billing if network is inadequate

Note

Use of Letters of Agreement / Single‑case Agreements

Use of Letters of Agreement / Single‑Case Agreements: SCAs and LOAs are operational tools, not replacements for contracting. BSWHP does not use local access plans in lieu of contracting; these agreements are temporary measures while the plan pursues permanent network solutions (e.g., recruiting providers, expanding contracting). Contracting duties are not delegated; credentialing may be delegated only after a pre‑delegation assessment. The Network Issues Committee and business expansion strategies guide efforts to improve network adequacy and reduce future reliance on SCAs/LOAs.

Access plan is used only when no providers are available to contract within the service area
BSWHP will continue active attempts to contract and expand the network to eliminate recurring need for SCAs/LOAs
Credentialing delegation requires pre‑delegation assessment

Key Terms & Definitions

Required distance standards (30 miles for primary care/general hospital; 75 miles for specialty care)

Primary care / general hospital maximum distance30 miles

Specialty care maximum distance75 miles

AuthorityTAC S11.1607(h)

Processes and procedures (including Letters of Agreement and Single-Case Agreements) to provide in-network benefits when network lacks providers

PurposeNegotiate Letter of Agreement or Single-Case Agreement with out-of-network provider to ensure member receives in-network benefit coverage

Member protectionAgreements include hold-harmless language preventing providers from billing members for services covered under the agreement

Contracting escalationContracting team will research and begin contracting when member cannot obtain specialized services in-network

Access plan — mechanism and non-substitution rule

DefinitionAccess plan — mechanism used when there are no available in-network providers to ensure members can access authorized services

ConstraintAccess plan is not used as a substitute for contracting with local providers

Operational useAccess plan implemented while contracting efforts continue to secure in-network providers

Hold-harmless language definition

DefinitionHold-harmless language — contractual clause where provider agrees not to seek reimbursement from or have recourse against the member for services provided under the agreement (including plan non-payment or insolvency)

ApplicationIncluded in single-case agreements and Letters of Agreement to protect members from balance billing

Enforcement contextApplies when out-of-network provider renders services under negotiated agreement to be paid by plan

Pre-delegation assessment definition

DefinitionPre-delegation assessment — evaluation completed before delegating credentialing to a provider group to ensure the group meets BSWHP regulatory standards

When requiredPerformed when credentialing is delegated to a group with multiple providers

PurposeEnsure delegated credentialing adheres to the Plan's regulatory standards

Single-case agreement / Letter of Agreement definition

DefinitionSingle-case agreement / Letter of Agreement — negotiated agreement with an out-of-network provider to render services to a member at in-network benefit levels

Member impactMember receives in-network benefit coverage and is protected from balance billing under these agreements

Contract requirementAgreements include hold-harmless language preventing provider recourse against members

Access plan (clarification)

ClarificationAccess plan is used only when no providers are available to contract within the service area; it supplements contracting efforts but does not replace them

Operational noteBSWHP maintains policies and procedures to enable members to access authorized services as in-network across counties and specialties

Network improvementPlan pursues contracting and business expansion to reduce future reliance on access plans

Pre-delegation assessment (clarification)

ClarificationPre-delegation assessment is completed to ensure delegated groups follow the same regulatory standards as BSWHP

When appliedUsed prior to delegating credentialing to provider groups with multiple providers

PurposeProtects member safety and regulatory compliance when credentialing is delegated

access plan (term repeat)

Term repeatAccess plan — used only when no local providers available to contract; not used instead of contracting

Financial noteNo anticipated cost savings from using access plan because it is not a substitute for contracting

OversightNetwork Issues Committee monitors access issues monthly

single-case agreement / letter of agreement (term repeat)

Term repeatSingle-case agreement / Letter of Agreement — negotiated to ensure member receives in-network benefits; includes hold-harmless language

Member protectionProvider agrees not to bill or seek reimbursement from member for services under agreement

Use caseApplied when required specialty/service is not available in-network in member's area

pre-delegation assessment (term repeat)

Term repeatPre-delegation assessment — review prior to delegating credentialing to ensure compliance with BSWHP standards

ApplicabilityPerformed when groups request credentialing delegation

OutcomeAllows credentialing delegation only if assessment confirms equivalence to Plan standards

Access plan (term repeat)

Term repeatAccess plan — processes and procedures (including Letters of Agreement and Single-Case Agreements) enabling members to utilize authorized services as in-network where network lacks providers

Not substitutionExplicitly not used in place of contracting

ImplementationNegotiation of agreements and contracting team actions occur when gaps identified

Single-case agreement / Letter of Agreement (definition repeat)

Definition repeatSingle-case agreement / Letter of Agreement — contract with out-of-network provider including hold-harmless to ensure member protection

IncludesHold-harmless clause preventing provider from seeking reimbursement from the member

Used alongsideContracting efforts to secure in-network providers

Pre-delegation assessment (term repeat)

Term repeatPre-delegation assessment — required before delegating credentialing to a group; ensures regulatory equivalence

ProcessAssessment completed when group has multiple providers prior to delegation

GuaranteeEnsures delegated credentialing follows Plan standards

Hold-harmless language (definition)

DefinitionHold-harmless language — provider agrees not to seek reimbursement from member for services provided under agreement, including in event of Plan non-payment or insolvency

UsageIncluded in single-case agreements and Letters of Agreement to protect members

EffectPrevents balance billing by provider for services covered under agreement

Access plan (term repeat)

Term repeatAccess plan — fallback mechanism used only when no providers available to contract locally

Network actionPlan pursues contracting and business expansion to reduce reliance on access plans

DocumentationAccess plan procedures described across county/specialty sections

Single-case agreement / Letter of Agreement (definition repeat)

Definition repeatSingle-case agreement / Letter of Agreement — negotiated contract to provide services at in-network benefit levels when no in-network provider available

Member protectionAgreements include hold-harmless language preventing provider recourse against members

Operational stepExecuted while contracting team works to bring provider into network

ACCESS PLAN (term repeat)

Term repeatACCESS PLAN — processes/procedures to make services available and accessible to enrollees where network lacks sufficient providers

MechanismsIncludes negotiation of Letters of Agreement and Single-Case Agreements

MonitoringNetwork Issues Committee and leadership evaluate adequacy and gaps

Single-case agreement / Letter of Agreement (definition repeat)

Definition repeatSingle-case agreement / Letter of Agreement — agreement that includes hold-harmless language to ensure member is not billed for services covered by the agreement

When usedWhen required specialty/service is not available in-network in member's area

Responsible teamContracting team negotiates and initiates agreements

Access plan (term repeat)

Term repeatAccess plan — not used in lieu of contracting; used only when no providers available

Financial implicationNo projected claims cost savings from access plan

Plan actionContinue contracting efforts even when access plan used

Pre-delegation assessment (definition repeat)

Term repeatPre-delegation assessment — review prior to delegating credentialing to ensure group meets BSWHP regulatory standards

ConditionRequired when delegating credentialing to provider groups with multiple providers

PurposeEnsure delegated credentialing follows Plan standards

Access plan (term repeat)

Term repeatAccess plan — processes to enable members to use authorized services as in-network where network lacks sufficient providers

Not substitutionExplicitly not used as replacement for contracting

MechanismIncludes Letters of Agreement and Single-Case Agreements

Single-case agreement / Letter of Agreement (definition with hold-harmless)

Definition with hold-harmlessLetter of Agreement / Single-case Agreement that includes hold-harmless language preventing provider recourse against member for non-payment or insolvency

Member effectMember will not be balance-billed for services under the agreement

Plan actionContracting team negotiates agreements when network inadequate

Pre-delegation assessment (definition repeat)

Term repeatPre-delegation assessment — required evaluation before delegating credentialing to ensure compliance with Plan standards

ApplicationPerformed for groups with multiple providers before delegation

GoalMaintain regulatory and quality standards under delegation

Access plan (term repeat)

Term repeatAccess plan — fallback mechanism used only when no providers available to contract; not a substitute for contracting

DocumentationAccess plan procedures are described across county and specialty sections

OversightLeadership and Network Issues Committee monitor and address gaps

Single-case agreement (term repeat)

Term repeatSingle-case agreement — negotiated contract with out-of-network provider to render services at in-network benefit levels

IncludesHold-harmless language to protect members from balance billing

Used whenRequired specialty/service not available in-network

Access plan (term repeat)

Term repeatAccess plan — implemented only when local contracting cannot provide an available provider; not used instead of contracting

Network improvementPlan will attempt to improve network to eliminate need for waivers

No savingsAccess plan use does not generate projected savings because it is not a contracting substitute

Single-case agreement / Letter of Agreement (term repeat with hold-harmless)

Term repeatSingle-case agreement / Letter of Agreement — includes hold-harmless language protecting members from provider recourse

Operational noteNegotiated when member cannot access required specialty in-network

Contracting follow-upContracting team will pursue longer-term contracting solutions

Provider directory listing practice addresses

Provider directory practiceProvider directory may list individual providers multiple times at different practice addresses to reflect availability

ReasonProviders may rotate locations or work multiple sites to ensure coverage

EffectRepeated listings are considered acceptable for availability/accessibility of care

access plan (term repeat)

Term repeatAccess plan — used only when no providers available to contract; not a substitute for contracting

Financial noteNo estimated cost savings to the Plan from access plan use

ImplementationNegotiation of agreements and contracting pursued concurrently

pre-delegation assessment (term repeat)

Term repeatPre-delegation assessment — evaluation completed before delegating credentialing to ensure group meets BSWHP regulatory standards

When usedApplied when delegating credentialing to groups that have multiple providers

PurposeEnsure delegated credentialing adheres to Plan standards and regulatory requirements

Access plan (term repeat)

Term repeatAccess plan — processes and procedures enabling in-network benefit access when network lacks providers

Not substitutionAccess plan is not used instead of contracting

MechanismsSingle-case agreements and Letters of Agreement are primary tools

Letter of Agreement / Single-case Agreement (term repeat with hold-harmless)

Term repeatLetter of Agreement / Single-case Agreement — contractual arrangement including hold-harmless protecting members from balance billing

When usedWhen required specialty or service is not available in-network in a county or area

ProcedureContracting team negotiates and executes agreement to render services as in-network

Pre-delegation credentialing assessment

DefinitionPre-delegation credentialing assessment — review performed before delegating credentialing to a provider group to ensure compliance with Plan regulatory standards

RequirementCompleted when credentialing delegation is considered for groups with multiple providers

PurposeMaintain quality and regulatory equivalence under delegated credentialing

Access plan (term repeat)

Term repeatAccess plan — fallback mechanism used only when no providers are available to contract locally

DocumentationAccess plan procedures and county/specialty specifics documented across plan sections

No savingsAccess plan not expected to produce cost savings since not used instead of contracting

Single-case agreement (term repeat)

Term repeatSingle-case agreement — negotiated contract with out-of-network provider to render services as in-network; includes hold-harmless

Member protectionProvider agrees not to bill member for services covered by the agreement

ProcessContracting team identifies provider and initiates single-case agreement when network lacks required specialty

Pre-delegation assessment (term repeat)

Term repeatPre-delegation assessment — review required before delegating credentialing to ensure group meets Plan regulatory standards

ApplicabilityPerformed when delegating credentialing to provider groups with multiple providers

ObjectiveEnsure delegated credentialing is equivalent to Plan standards

access plan (term repeat)

Term repeataccess plan — processes and procedures to provide in-network benefits where network lacks sufficient providers

Non-substitutionNot used in lieu of contracting; contracting efforts continue

ToolsSingle-case agreements and Letters of Agreement used to render services as in-network

single-case agreement / Letter of Agreement (definition repeat)

Term repeatsingle-case agreement / Letter of Agreement — negotiated agreement with hold-harmless protecting members from provider recourse

Use caseApplied when required specialty/service unavailable in-network

Member protectionPrevents providers from seeking reimbursement from members for services under the agreement

OpenPayer

Access plan for inadequate network coverage

When Network Is Inadequate — Coverage & Access Rules

Contracting & Operational Steps for Providers / Contracting Team

Access Radius, Codes, and Key Quantitative Thresholds

Key Terms & Definitions