CurrentBaylor Scott & White Health PlanPolicy N/A

HMO Access Plan — Network Adequacy and TDI/TAC Distance Standard Exceptions

Describes Scott & White Health Plan's processes to meet Texas HMO network adequacy standards, identify geographic areas lacking providers, and provide in‑network benefits when network providers are unavailable; applies to the plan's HMO network and its enrollees in Texas.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyHMO Access Plan — Network Adequacy and TDI/TAC Distance Standard Exceptions

Policy CodePolicy N/A

Change TypeNo material change (administrative review)

Effective DateN/A

Next Review DateN/A

Key ActionNegotiate a Letter of Agreement or execute a Single Case Agreement with an out-of-network provider so the member receives in-network benefit coverage and is protected from balance billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30/75 miTDI/TAC distance

In‑network payFallback payment

SCAs/LOAsContracting tools

monthlyReview cadence

many TX countiesAffected counties

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Coverage stance & payment rules when network providers are unavailable

In-network treatment of out-of-network providers when network inadequate

Coverage stance and operational response when network providers are not available within TAC/TDI distance standards:

ALL of the following

SWHP will negotiate a Letter of Agreement or execute a Single Case Agreement with an identified out-of-network provider to treat services as in-network for the affected member, including hold-harmless language to prevent balance billing.
When no contracted provider is available within the TDI/TAC distance standards, the facility/provider will be paid at the in-network benefit level as specified in the Texas Administrative Code.

Covered member will not be balance billed or penalized due to network inadequacy; members will not be denied other benefits because of network gaps.

In‑network payment when contracted provider unavailable

Coverage/payment stance when contracted providers are unavailable within TDI distance standards in specified Texas counties and specialties.

If a contracted provider for the listed county or specialty is not available within the TDI distance standards, then the facility/provider will be paid at the in-network benefit level as specified in the Texas Administrative Code.

Freedom of Choice / Limited Choice status for affected counties/provider types is referenced in the Access Plan Overview tab (see plan documentation).

In-network payment fallback

Payment rule when no contracted provider is available within the TDI distance standards:

If a contracted provider for the listed specialty/county is not available within the TDI distance standards, the facility/provider will be paid at the in-network benefit level as specified in the Texas Administrative Code.

Many counties and specialties in the record are marked as 'are not available to contract'; the payment fallback applies to those entries.

In-network payment when no contracted provider within TDI distance

Payment rule when network providers are not available within TDI standards for listed counties/provider types.

When no contracted provider is available within the TDI distance standards for a listed county or provider type, the facility/provider will be paid at the in-network benefit level per the Texas Administrative Code.

Freedom of Choice / Limited Choice guidance

Reference to plan-level choice provisions.

Freedom of Choice or Limited Choice status for specific counties/provider types is addressed in the Access Plan Overview tab; consult that overview for plan-level choice details.

In-network payment rule when contracted providers unavailable

Coverage/payment stance when network providers are unavailable within TDI standards for listed services/counties.

For behavioral health program types (e.g., PHP, RTC, Chemical Dependency IOP/PHP) where no contracted provider exists within the TDI distance standards in the member's county or area, the facility/provider will be paid at the in-network benefit level as specified in the Texas Administrative Code.

Access and payment rules for facilities without in-network providers

Facility-specific coverage/contract notes and payer stance when network providers are unavailable within regulatory distance standards.

When a contracted provider is not available within the TDI distance standards for a listed facility, the facility/provider will be paid at the in-network benefit level as specified in the Texas Administrative Code.

Facility entries may include status notes such as 'Are not available to contract', 'Services not offered at facility', 'No Deficiencies', or 'See attempt to contract' which document contracting attempts and availability reasons.

This rule applies to the listed facilities and counties within the document portion (Texas).

Payment rule for lack of nearby contracted provider

When no contracted provider exists within TDI distance standards in Texas for a given facility/service:

If a contracted provider is not available within the TDI distance standards for the specified facility or service, the provider will be paid at the in-network benefit level as specified in the Texas Administrative Code.

Facility records include contracting status indicators (e.g., 'Are not available to contract', 'Services not offered at facility', 'No Deficiencies'); these indicators inform but do not alter the payment fallback.

TDI fallback and facility contracting status

Coverage/payment stance when contracted providers are unavailable within TDI distance standards for listed facilities:

If no contracted provider is available within the TDI distance standards, the provider will be paid at the in-network benefit level per the Texas Administrative Code.

Facility contracting status may be:

'See attempt to contract'
'Are not available to contract'
'No Deficiencies'

TDI distance standard payment exception

Payment rule when contracted provider unavailable within TDI distance standards

If a contracted provider is not available within the TDI distance standards, the provider will be paid at the in-network benefit level as specified in the Texas Administrative Code.

Coding, distance standards and related key values

Not specified in this sectionmixed

No codes listed

Provider types mentionedmixed

No codes listed

mixed

No codes listed

Distance standards — 30 miles / 75 miles

TDI/TAC distance standards30 miles for primary care and general hospital care; 75 miles for specialty care, specialty hospitals, and single healthcare service providers (TAC §11.1607(h))

PurposeEstablishes maximum travel distances used to evaluate HMO network adequacy across service areas

Applies toAll covered services and providers when assessing network availability within the plan's service area

TDI distance standard — applies to determine payment at in‑network level

Use of TDI distance standardTDI distance standard is applied to determine when a contracted provider is not available and to trigger payment at the in‑network benefit level

Operational steps for arranging in-network benefits and payment

Prior Authorization

Single Case Agreement / Letter of Agreement process

Negotiate and execute a Single Case Agreement or Letter of Agreement with an identified out-of-network provider so the member receives in-network benefit coverage; include hold‑harmless language to prevent balance billing of the member.

Contracting team will research and identify a provider and execute a Single Case Agreement once a provider is identified.
Single case agreements and letters of agreement include hold‑harmless language: 'Provider hereby agrees that in no event... shall Provider charge, collect a dHMOsit from, seek compensation... from Member.'

Billing Rule

Payment when contracted provider unavailable

If a contracted provider is not available within the Texas Department of Insurance (TDI) distance standards, the facility/provider will be paid at the in‑network benefit level as specified in the Texas Administrative Code.

Key terms and regulatory references

Access plan definition (TAC §11.1607(j))

DefinitionAccess plan — a plan submitted under TAC §11.1607(j) describing geographic areas lacking providers, reasons for unavailability, maps, and HMO plans to make services available

Required contentsMust identify geographic area, reasons services/providers cannot be made available, map, plan to make services available, and provider listings (TAC §11.1607(j)(1)-(6))

When requiredWhen covered services or participating providers are not available within the mileage radii specified in TAC §11.1607(h)

Single Case Agreement / Letter of Agreement definition

DefinitionSingle Case Agreement / Letter of Agreement — contractual mechanism to treat an out‑of‑network provider as in‑network for specific services when the network lacks sufficient providers; includes hold‑harmless language to prevent member balance billing

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyHMO Access Plan — Network Adequacy and TDI/TAC Distance Standard Exceptions

Policy CodePolicy N/A

Change TypeNo material change (administrative review)

Effective DateN/A

Next Review DateN/A

Key ActionNegotiate a Letter of Agreement or execute a Single Case Agreement with an out-of-network provider so the member receives in-network benefit coverage and is protected from balance billing.

SourceLink

On This Page

Referenced throughout facility- and county-level entries as the criterion for invoking in‑network payment for out‑of‑network providers

Regulatory basisApplied per Texas Administrative Code guidance as noted in access plan facility entries

Billing Rule

Payment when no contracted provider available

When no contracted provider exists within the TDI distance standards for the listed specialty or county, the facility/provider will be paid at the in‑network benefit level per the Texas Administrative Code.

Billing Rule

Payment when no contracted provider within TDI distance

If a contracted provider is not available within the TDI distance standards for the listed county/provider type, the facility/provider will be paid at the in‑network benefit level as specified in the Texas Administrative Code.

Documentation Required

Freedom of Choice / Limited Choice reference (Overview tab)

Freedom of Choice or Limited Choice status for affected counties and provider types is documented in the Overview tab of the Access Plan.

Billing Rule

Fallback payment when no contracted provider within TDI distance

Fallback payment rule: when no contracted provider is available within the TDI distance standards, the facility/provider will be paid at the in‑network benefit level as specified in the Texas Administrative Code.

Billing Rule

Payment when no contracted provider within TDI distance (facility-level)

For listed facilities where no contracted provider is available within TDI distance standards, the facility/provider will be paid at the in‑network benefit level in accordance with the Texas Administrative Code.

Facility entries note contracting status (e.g., 'Are not available to contract', 'Services not offered at facility', 'No Deficiencies', 'See attempt to contract').

Billing Rule

General payment rule when no contracted provider within TDI distance

General payment rule: when no contracted provider is available within the TDI distance standards, pay the provider at the in‑network benefit level as specified in the Texas Administrative Code.

Billing Rule

TDI distance standard payment fallback (provider paid at in-network level)

Under the TDI distance standard fallback, if no contracted provider exists within the prescribed TDI distances, the provider will be paid at the in‑network benefit level per the Texas Administrative Code.

Billing Rule

Payment rule when no contracted provider within TDI distance (general)

Payment rule reiterated: if a contracted provider is not available within the TDI distance standards, the provider will be paid at the in‑network benefit level as specified in the Texas Administrative Code.

Executed immediately after identifying an available out‑of‑network provider to enable in‑network authorization and benefits

Related processUsed alongside contracting team activities and recorded contracting attempts in the access plan

Freedom of Choice/Limited Choice — definition/reference

DefinitionFreedom of Choice / Limited Choice — plan-level status describing whether members have unrestricted or limited provider choice; addressed in the Access Plan Overview tab

Location in planStatus and details for Freedom of Choice or Limited Choice are recorded in the Access Plan Overview tab

ImplicationChoice status informs how the plan documents alternatives when network providers are not available

TDI distance standards — definition/reference

DefinitionTDI distance standards — distance thresholds established by the Texas Department of Insurance used to determine whether a contracted provider is considered available to members

ApplicationIf no contracted provider exists within these mileage standards, payment and access rules in the access plan apply (facility/provider may be paid at in‑network level)

Regulatory citationReferenced in multiple county and specialty entries as the trigger for access/payment rules per Texas Administrative Code

TDI distance standards — repeated reference

RestatementTDI distance standards — used consistently in the access plan entries to determine network adequacy and invoke in‑network payment when unmet

EvidenceRepeated facility/county entries state: 'If a contracted provider is not available within the TDI distance standards, the facility/provider will be paid at the in‑network benefit level as specified in the Texas Administrative Code.'

ScopeApplies across specialties, facilities, and behavioral health program types listed in the plan

Freedom of Choice or Limited Choice — Access Plan Overview tab note

Access Plan noteFreedom of Choice or Limited Choice status is referenced in the Access Plan Overview tab for behavioral health and other provider types

Behavioral health entriesAccess plan entries for IOP/PHP/RTC frequently include the Freedom of Choice/Limited Choice note in the Overview tab

Operational effectChoice designation is recorded but does not negate the use of single case agreements or in‑network payment fallback when distance standards are unmet

TDI distance standards — regulatory description

Regulatory descriptionTDI/TAC distance standards set maximum travel distances (30/75 miles) used to assess availability of contracted providers; when unmet, the access plan mechanism applies

Trigger for access actionsUnavailability within these standards requires an access plan and may trigger single case agreements or payment at in‑network benefit levels

Referenced program typesSpecifically applied to behavioral health program types (PHP/RTC/IOP) and other specialties in the plan entries

Freedom of Choice or Limited Choice — plan-level option referenced

Plan‑level optionFreedom of Choice or Limited Choice — recorded as a plan‑level designation in the Access Plan Overview tab and applied to specified counties/provider types

DocumentationAccess plan entries repeatedly note 'Freedom of Choice or Limited Choice is addressed in the Overview tab of the Access Plan'

Interaction with access actionsDesignation does not preclude use of TDI distance standards or single case agreements when network adequacy fails

TDI distance standards — geographic/network access thresholds

Geographic/network thresholds30 miles for primary care/general hospital; 75 miles for specialty care and specialty hospitals — applied to counties/facilities listed in the access plan

Operational effectIf providers are not located within these thresholds or cannot be contracted after good faith attempts, an access plan must be submitted and access remedies applied

Used to invoke payment ruleMultiple facility and county entries state failure to meet these thresholds leads to paying out‑of‑network providers at the in‑network benefit level per Texas Administrative Code

Behavioral health program types (PHP/RTC/CD IOP/PHP)

Behavioral health program typesBehavioral Health Partial Hospitalization Program (PHP); Residential Treatment Center (RTC); Chemical Dependency Intensive Outpatient Program (IOP); Behavioral Health Intensive Outpatient Program (IOP)

ApplicationThese program types are listed in county entries where providers are 'Are not available to contract' and the TDI distance standards invoke in‑network payment fallback

DocumentationPlan entries for Menard, Mills, Reagan, Runnels, San Saba, Kimble, Llano, Mason, McCulloch, and others reference these program types

TDI distance standards — additional ref

Additional citationTDI distance standards are reiterated in facility-level entries; failure to locate contracted providers within the standards triggers payment at the in‑network benefit level

Facility examplesBaylor Scott & White Emergency Medical Center - Cedar Park and Baylor University Medical Center entries reference the TDI standard and in‑network payment fallback

Consistent phrasingFacility entries repeatedly state: 'If a contracted provider is not available within the TDI distance standards, the provider will be paid at the in‑network benefit level as specified in the Texas Administrative Code.'

Freedom of Choice or Limited Choice (additional ref)

Freedom of Choice / Limited Choice — additional noteAccess plan entries consistently note that Freedom of Choice or Limited Choice is addressed in the Overview tab of the Access Plan

Application areasReferenced across county-level and behavioral health entries where providers are unavailable to contract

RecordkeepingUsed to document whether members have choice or are limited in provider selection in the affected areas

TDI distance standards — regulatory description

Regulatory summaryTDI distance standards per TAC §11.1607(h) set 30/75 mile thresholds; TAC §11.1607(j) requires an access plan and remedies when services/providers are not available within those radii

Effect on paymentWhen standards are unmet, the access plan and Texas Administrative Code language are used to pay out‑of‑network providers at the in‑network benefit level

RepetitionMultiple access plan entries reference these regulatory criteria as the basis for invoking the plan's remedies

TDI distance standard fallback — payment at in‑network benefit when no contracted provider available

Fallback payment ruleIf no contracted provider is available within the TDI distance standards, the facility/provider will be paid at the in‑network benefit level as specified in the Texas Administrative Code

Where documentedStated repeatedly in county and facility entries (examples: Kimble Oncology; Baylor University Medical Center) as the payment approach when network adequacy fails

Operational implicationEnables members to receive in‑network benefits and protects them from balance billing when the network lacks providers within the standards

TDI distance standard exception — payment at in‑network benefit when no contracted provider available

Payment exceptionPayment at the in‑network benefit level is applied when no contracted provider is available within TDI distance standards, per Texas Administrative Code

Documented useFacility and county entries (El Paso, Kimble, Baylor facilities, etc.) explicitly state this exception and the plan's use of single case agreements/letters of agreement to provide in‑network access

Member protectionAccess plan language and hold‑harmless provisions in single case agreements ensure members are not balance billed when this exception is used