CurrentBaylor Scott & White Health PlanPolicy SWHP PNO.044.P

TDI Regulatory filing requirements for Commercial Networks

Governance of Texas Department of Insurance (TDI) network adequacy and filing requirements for Baylor Scott & White Health Plan commercial products (EPO, PPO, HMO) operating in Texas.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyTDI Regulatory filing requirements for Commercial Networks

Policy CodePolicy SWHP PNO.044.P

Change TypeNo material changes

Effective DateDec 30, 2020

Next Review DateN/A

Key ActionProvide contracted provider maps and listings, access plan justification, and complete FIN543 annual report (and waiver request/access plan checklist where applicable).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 milesmax travel distance for PCP and general hospital in non-rural/service area

60 milesmax travel distance for PCP and general hospital in rural areas (EPO/PPO)

75 milesmax travel distance for specialty care and specialty hospitals

Commercial ALLlines of business covered

FIN543

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Network Adequacy & Filing Requirements

Network adequacy criteria and filing deliverables

Network adequacy and filing requirements that must be met for EPO, PPO, and HMO products:

ALL of the following

Distance requirements
- For EPO and PPO: travel distance from any point in the designated service area to a point of service must not exceed 30 miles in non-rural areas for Primary Care Provider (PCP) and general hospital care.
- For EPO and PPO: travel distance from any point in the designated service area to a point of service must not exceed 60 miles in rural areas for Primary Care Provider (PCP) and general hospital care.
- For EPO, PPO and HMO: travel distance from any point in the service area to a point of service must not exceed 75 miles for specialty care and specialty hospitals (Specialty Care Provider, SCP).
HMO specific: HMO must provide an adequate network for its entire service area such that covered services are accessible and available within the stated travel distances (30 miles for PCP/general hospital; 75 miles for specialty care).
Documentation and deliverables
- Submit contracted provider maps identifying locality of contracted providers in the geographic health plan service area.
- Provide contracted provider listings that include demographic information and credentialing dates.
- Provide an access plan justification documenting identified gaps in professional healthcare services and alternate access to care.
- Provide access plan provider listings and maps showing contracted providers (with demographic information and credentialing dates) that fulfill identified gaps.
- Complete and submit the FIN543 annual report; where applicable, include waiver requests and the access plan checklist.
Regulatory basis: Compliance is based on Texas Insurance Code provisions and Texas Administrative Code requirements referenced in policy (e.g., TIC 1301.005, TIC 1301.006, 28 TAC provisions for network adequacy and filing requirements).

Regulatory Citations and Travel Thresholds

Relevant Texas Administrative Code citationsmixed

28 TAC 83.3704	Freedom of Choice; Availability of Preferred Providers
28 TAC 83.3707	Waiver Due to Failure to Contract in Local Markets
28 TAC 83.3709	Annual Network Adequacy Report / Failure to Provide an Adequate Network
28 TAC 811.1607	Accessibility and Availability Requirements
28 TAC 811.301	Filing Requirements
28 TAC 811.302	Service Area Expansion or Reduction Applications

Travel distance thresholds

PCP/general hospital - non-rural30 miles

PCP/general hospital - rural (EPO/PPO)60 miles

Specialty care and specialty hospitals75 miles

Documentation & Filing Deliverables

Documentation Required

Documentation and deliverables required for network filings

Provide the following deliverables for EPO, PPO, and HMO network filings: contracted provider maps showing provider localities in the service area; a contracted provider listing including demographic information and credentialing dates; an access plan justification describing identified gaps and alternate access to care; access plan provider listings and maps (including demographic info and credentialing dates) that demonstrate how gaps will be fulfilled; and completion of the FIN543 annual report, waiver request, and access plan checklist.

Contracted provider maps identifying locality of contracted providers in geographic health plan service area.
Contracted provider listing that includes demographic information and credentialing dates.
Access plan justification of identified gaps in professional healthcare services and alternate access to care.
Access plan provider listings of contracted providers that include demographic information and credentialing dates to alternate professional healthcare services.
Access plan provider maps identifying the locality that fulfill the gaps in healthcare professional services.
Completion of FIN543 annual report, waiver request, and access plan checklist.

Key Terms

Definitions (general)

Document-specific definitionsNo specific defined terms provided in this document; refer to the BSWH P&P Definitions document for plan-wide definitions.

Usage noteWhen used with initial capital letters, terms carry meanings set in this document or BSWH P&P Definitions as applicable.

Location of additional definitionsSee BSWH P&P Definitions (external policy document) for any terms not defined here.

PCP

PCP (Primary Care Provider)Referenced in travel distance requirements: maximum travel distance 30 miles (non-rural) and 60 miles (rural, EPO/PPO) to PCP and general hospital care.

Role contextPCPs are used as the access standard for primary care network adequacy under TDI requirements.