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Texas Department of Insurance
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PPO and EPO networks

Insurance Code Chapter 1301 authorizes preferred and exclusive provider benefit plans, typically referred to as PPO and EPO plans. PPOs and EPOs offer healthcare coverage through a network of doctors, hospitals, and other health care providers. TDI is responsible for ensuring these networks are adequate, consistent with the requirements in the Texas Insurance Code (TIC) Chapter 1301 and in 28 Texas Administrative Code (TAC) Chapter 3, Subchapter X.

House Bill 3359, 88th Legislature, 2023 added new health plan network adequacy standards for preferred provider and exclusive provider benefit plans. In 2024, TDI adopted rule updates to implement HB 3359 and specify how insurers must demonstrate compliance with network adequacy requirements and request waivers if there are network gaps. Referenced in the rules are new network adequacy reporting forms that were also developed to implement the updated network adequacy standards.

Access the new EPO/PPO forms.

Under Texas Insurance Code §1301.0055, when a network does not meet specified time and distance requirements and appointment wait times in a county for a specific provider specialty type, an insurer must apply for a waiver to operate within its service area with the identified network gaps. TDI's commissioner may grant a waiver if good cause is shown after consideration of relevant testimony and information following a virtual public hearing. Health care providers and consumers can share related information, which TDI will consider when it decides whether to grant the waiver request. Learn more about network adequacy waiver hearings.

Initial application

Before offering a PPO or EPO plan in Texas, an insurer must:

  • Undergo a qualifying examination/review.
  • Submit an application and supporting documentation as required by 28 TAC Chapter 3, Subchapter X, for review and approval by three TDI program areas:
    • Accident and Health (policy and certificate of coverage)
    • Managed Care Quality Assurance (network configuration)
    • Market Conduct Examinations (qualifying examination)
You may not market a PPO or EPO product until all three program areas approve your application.

Annual network adequacy report

On or before April 1 of each year and before marketing any PPO or EPO plan in a new service area, insurers must file a network adequacy report with the department. The insurer's annual network adequacy report must include all of the information described in 28 TAC §§3.3709 and 3.3712. If the network contains any gaps in service or coverage for enrollees in the contracted network, the insurer must file a waiver request and access plan with the department for approval.

EPO/PPO forms

Under 28 TAC §§3.3709 and 3.3712, insurers must submit network configuration information using the following forms.

Major medical

Vision

Filer's guide

For more information, contact: MCQA@tdi.texas.gov

Last updated: 1/22/2026