reglab/housing_qa huggingface dataset:
TX Ins Code § 843.350 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.350. Overpayment

Sec. 843.350.  OVERPAYMENT.  (a)  A health maintenance organization may recover an overpayment to a physician or provider if:(1)  not later than the 180th day after the date the physician or provider receives the payment, the health maintenance organization provides written notice of the overpayment to the physician or provider that includes the basis and specific reasons for the request for recovery of funds;  and(2)  the physician or provider does not make arrangements for repayment of the requested funds on or before the 45th day after the date the physician or provider receives the notice.(b)  If a physician or provider disagrees with a request for recovery of an overpayment, the health maintenance organization shall provide the physician or provider with an opportunity to appeal, and the health maintenance organization may not recover the overpayment until all appeal rights are exhausted.|Added by Acts 2003, 78th Leg., ch. 214, Sec. 19, eff. June 17, 2003.|
TX Ins Code § 843.351 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.351. Services Provided by Certain Physicians and Providers

Sec. 843.351.  SERVICES PROVIDED BY CERTAIN PHYSICIANS AND PROVIDERS.  The provisions of this subchapter relating to prompt payment by a health maintenance organization of a physician or provider and to verification of health care services apply to a physician or provider who:(1)  is not included in the health maintenance organization delivery network;  and(2)  provides to an enrollee:(A)  care related to an emergency or its attendant episode of care as required by state or federal law;  or(B)  specialty or other health care services at the request of the health maintenance organization or a physician or provider who is included in the health maintenance organization delivery network because the services are not reasonably available within the network.|Added by Acts 2003, 78th Leg., ch. 214, Sec. 19, eff. June 17, 2003.|
TX Ins Code § 843.352 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.352. Conflict With Other Law

Sec. 843.352.  CONFLICT WITH OTHER LAW.  To the extent of any conflict between this subchapter and Subchapter C, Chapter 1204, this subchapter controls.|Added by Acts 2003, 78th Leg., ch. 214, Sec. 19, eff. June 17, 2003.Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.050, eff. April 1, 2009.|
TX Ins Code § 843.353 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.353. Waiver Prohibited

Sec. 843.353.  WAIVER PROHIBITED.  Except as provided by Sections 843.336(f) and 843.337(c), the provisions of this subchapter may not be waived, voided, or nullified by contract.|Added by Acts 2003, 78th Leg., ch. 214, Sec. 19, eff. June 17, 2003.|
TX Ins Code § 843.354 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.354. Legislative Declaration

Sec. 843.354.  LEGISLATIVE DECLARATION.  It is the intent of the legislature that the requirements contained in this subchapter regarding payment of claims to providers who are pharmacists or pharmacies apply to all health maintenance organizations and pharmacy benefit managers unless otherwise prohibited by federal law.|Added by Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 6, eff. September 1, 2011.|
TX Ins Code § 843.361 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter K. Relations Between Enrollee and Physician or Provider|Section 843.361. Enrollees Held Harmless

Sec. 843.361.  ENROLLEES HELD HARMLESS.  A contract or other agreement between a health maintenance organization and a physician or provider must specify that the physician or provider will hold an enrollee harmless for payment of the cost of covered health care services if the health maintenance organization does not pay the physician or provider for those services.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.362 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter K. Relations Between Enrollee and Physician or Provider|Section 843.362. Continuity of Care; Obligation of Health Maintenance Organization

Sec. 843.362.  CONTINUITY OF CARE;  OBLIGATION OF HEALTH MAINTENANCE ORGANIZATION.  (a)  In this section, "special circumstance" means a condition regarding which a treating physician or provider reasonably believes that discontinuing care by that physician or provider could cause harm to an enrollee who is a patient.  Examples of an enrollee who has a special circumstance include an enrollee with a disability, acute condition, life-threatening illness, or who is past the 24th week of pregnancy.(b)  Each contract between a health maintenance organization and a physician and provider must provide that termination of the contract, except for reason of medical competence or professional behavior, does not release the health maintenance organization from the obligation of continuing to reimburse a physician or provider providing medically necessary treatment at the time of termination to an enrollee who has a special circumstance in accordance with the dictates of medical prudence.  Subject to Subsections (d) and (e), the health maintenance organization must provide continued reimbursement at not less than the contract rate in exchange for the enrollee's continued receipt of ongoing treatment from the physician or provider.(c)  The treating physician or provider shall identify a special circumstance.  The treating physician or provider must:(1)  request that an enrollee be permitted to continue treatment under the physician's or provider's care;  and(2)  agree not to seek payment from the enrollee of any amount for which the enrollee would not be responsible if the physician or provider continued to be included in the health maintenance organization delivery network.(d)  Except as provided by Subsection (e), this section does not extend the obligation of a health maintenance organization to reimburse a terminated physician or provider for ongoing treatment of an enrollee after:(1)  the 90th day after the effective date of the termination;  or(2)  if the enrollee has been diagnosed with a terminal illness at the time of termination, the expiration of the nine-month period after the effective date of the termination.(e)  If an enrollee is past the 24th week of pregnancy at the time of termination, a health maintenance organization's obligation to reimburse a terminated physician or provider or, if applicable, an enrollee extends through delivery of the child and applies to immediate postpartum care and a follow-up checkup within the six-week period after delivery.(f)  A contract between a health maintenance organization and a physician or provider must provide procedures for resolving disputes regarding the necessity for continued treatment by a physician or provider.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.363 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter K. Relations Between Enrollee and Physician or Provider|Section 843.363. Protected Physician or Provider Communications With Patients

Sec. 843.363.  PROTECTED PHYSICIAN OR PROVIDER COMMUNICATIONS WITH PATIENTS.  (a)  A health maintenance organization may not, as a condition of a contract with a physician, dentist, or provider, or in any other manner, prohibit, attempt to prohibit, or discourage a physician, dentist, or provider from discussing with or communicating in good faith with a current, prospective, or former patient, or a person designated by a patient, with respect to:(1)  information or opinions regarding the patient's health care, including the patient's medical condition or treatment options;(2)  information or opinions regarding the terms, requirements, or services of the health care plan as they relate to the medical needs of the patient;(3)  the termination of the physician's, dentist's, or provider's contract with the health care plan or the fact that the physician, dentist, or provider will otherwise no longer be providing medical care, dental care, or health care services under the health care plan; or(4)  information regarding the availability of facilities, both in-network and out-of-network, for the treatment of the patient's medical condition.(a-1)  A health maintenance organization may not, as a condition of payment with a physician, dentist, or provider, or in any other manner, require a physician, dentist, or provider to provide a notification form stating that the physician, dentist, or provider is an out-of-network provider to a current, prospective, or former patient, or a person designated by the patient, if the form contains additional information that is intended, or is otherwise required to be presented in a manner that is intended, to intimidate the patient.(b)  A health maintenance organization may not in any manner penalize, terminate, or refuse to compensate for covered services a physician, dentist, or provider for communicating in a manner protected by this section with a current, prospective, or former patient, or a person designated by a patient.(c)  A contract provision that violates this section is void.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.Amended by: Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574), Sec. 3, eff. September 1, 2015.|
TX Ins Code § 843.401 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter L. Financial Regulation of Health Maintenance Organizations|Section 843.401. Fiduciary Responsibility

Sec. 843.401.  FIDUCIARY RESPONSIBILITY.  A director, officer, member, employee, or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of the health maintenance organization is responsible for the funds in a fiduciary relationship to the enrollees.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.402 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter L. Financial Regulation of Health Maintenance Organizations|Section 843.402. Officers' and Employees' Bond

Sec. 843.402.  OFFICERS' AND EMPLOYEES' BOND.  (a)  A health maintenance organization shall maintain in force in its own name a fidelity bond on its officers and employees in an amount of at least $100,000 or another amount prescribed by the commissioner.(b)  The fidelity bond must be issued by an insurer that holds a certificate of authority in this state.  If, after notice and hearing, the commissioner determines that a fidelity bond is not available from an insurer that holds a certificate of authority in this state, the health maintenance organization may obtain a fidelity bond procured by a surplus lines agent resident in this state in compliance with Chapter 981.(c)  The fidelity bond must obligate the surety to pay any loss of money or other property the health maintenance organization sustains because of an act of fraud or dishonesty by an employee or officer of the health maintenance organization, acting alone or in concert with others, while employed or serving as an officer of the health maintenance organization.(d)  Instead of a fidelity bond, a health maintenance organization may deposit cash with the comptroller.  The deposit must be maintained in the amount and is subject to the same conditions required for a fidelity bond under this section.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.403 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter L. Financial Regulation of Health Maintenance Organizations|Section 843.403. Minimum Net Worth

Sec. 843.403.  MINIMUM NET WORTH.  (a)  A health maintenance organization authorized to provide basic health care services shall maintain a minimum net worth of $1.5 million.(b)  A health maintenance organization authorized to provide limited health care services shall maintain a minimum net worth of $1 million.(c)  A health maintenance organization authorized to offer only a single health care service plan shall maintain a minimum net worth of $500,000.(d)  The minimum net worth required by this section may consist only of:(1)  money of the United States;(2)  bonds of this state;(3)  bonds or other evidences of indebtedness of the United States that are guaranteed as to principal and interest by the United States;  or(4)  bonds or other interest-bearing evidences of indebtedness of a county or municipality of this state.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.404 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter L. Financial Regulation of Health Maintenance Organizations|Section 843.404. Additional Net Worth Requirements

Sec. 843.404.  ADDITIONAL NET WORTH REQUIREMENTS.  (a)  The commissioner may adopt rules or by rule establish guidelines requiring a health maintenance organization to maintain a specified net worth based on:(1)  the nature and kind of risks the health maintenance organization underwrites or reinsures;(2)  the premium volume of risks the health maintenance organization underwrites or reinsures;(3)  the composition, quality, duration, or liquidity of the health maintenance organization's investment portfolio;(4)  fluctuations in the market value of securities the health maintenance organization holds;(5)  the adequacy of the health maintenance organization's reserves;(6)  the number of individuals enrolled by the health maintenance organization;  or(7)  other business risks.(b)  Rules adopted or guidelines established under this section must be designed to ensure the financial solvency of health maintenance organizations for the protection of enrollees.  The rules or guidelines may provide for a health maintenance organization to comply with a risk-based net worth requirement established under this section in stages over a two-year period.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.406 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter L. Financial Regulation of Health Maintenance Organizations|Section 843.406. Hazardous Financial Condition

Sec. 843.406.  HAZARDOUS FINANCIAL CONDITION.  (a)  If the financial condition of a health maintenance organization indicates that the continued operation of the health maintenance organization could be hazardous to its enrollees or creditors or the public, the commissioner may, after notice and opportunity for hearing:(1)  suspend or revoke the health maintenance organization's certificate of authority;  or(2)  order the health maintenance organization to take action reasonably necessary to correct the condition, including by:(A)  reducing by reinsurance the total amount of present and potential liability for benefits;(B)  reducing the volume of new business being accepted;(C)  reducing expenses by specified methods;(D)  suspending or limiting for a period the writing of new business;  or(E)  increasing the health maintenance organization's capital and surplus by contribution.(b)  In a manner consistent with the purposes of this section, the commissioner by rule may establish:(1)  uniform standards and criteria for early warning that the continued operation of a health maintenance organization could be hazardous to the health maintenance organization's enrollees or creditors or the public;  and(2)  standards for evaluating the financial condition of a health maintenance organization.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.407 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter L. Financial Regulation of Health Maintenance Organizations|Section 843.407. Receivership and Delinquency Proceedings

Sec. 843.407.  RECEIVERSHIP AND DELINQUENCY PROCEEDINGS.  (a)  In addition to all other remedies available by law, if the commissioner believes that a health maintenance organization or another person is insolvent or does not maintain the net worth required under Sections 843.403, 843.4031, and 843.404, the commissioner may bring an action in a Travis County district court to be named receiver in accordance with Section 843.157 and Chapter 443.(b)  The court may:(1)  find that a receiver should take charge of the assets of the health maintenance organization; and(2)  name the commissioner as the receiver of the health maintenance organization in accordance with Section 843.157 and Chapter 443.(c)  The operations and business of a health maintenance organization represent the business of insurance for purposes of Section 843.157 and Chapters 441 and 443.(d)  Exclusive venue of receivership and delinquency proceedings for a health maintenance organization is in Travis County.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.051, eff. April 1, 2009.|
TX Ins Code § 843.408 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter L. Financial Regulation of Health Maintenance Organizations|Section 843.408. Insolvency and Allocation to Other Health Maintenance Organizations

Sec. 843.408.  INSOLVENCY AND ALLOCATION TO OTHER HEALTH MAINTENANCE ORGANIZATIONS.  (a)  If a health maintenance organization becomes insolvent, the commissioner shall equitably allocate the insolvent health maintenance organization's group contracts and nongroup enrollees among all health maintenance organizations that operate within a portion of the insolvent health maintenance organization's service area.  The commissioner shall allocate the group contracts by order.  In making allocations, the commissioner shall consider the resources of each health maintenance organization.(b)  A successor health maintenance organization to which one or more groups are allocated shall offer each group the successor health maintenance organization's coverage at rates determined in accordance with the successor health maintenance organization's existing methodology or in accordance with that methodology as adjusted by the commissioner.(c)  A successor health maintenance organization to which nongroup enrollees are allocated shall offer each nongroup enrollee the successor health maintenance organization's existing coverage for individual or conversion coverage, as determined by the nongroup enrollee's type of coverage from the insolvent health maintenance organization, at rates determined in accordance with the successor health maintenance organization's existing methodology or in accordance with that methodology as adjusted by the commissioner.  A successor health maintenance organization that does not offer direct nongroup enrollment shall provide coverage at rates that reflect the average group rate of the successor health maintenance organization.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.409 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter L. Financial Regulation of Health Maintenance Organizations|Section 843.409. Examination Expenses

Sec. 843.409.  EXAMINATION EXPENSES.  (a)  A credit against the amount of premium taxes to be paid by a health maintenance organization in a taxable year may not be allowed on:(1)  an examination fee or expense paid to another state;  or(2)  an examination expense:(A)  directly attributable to an examination of the books, records, accounts, or principal offices of a health maintenance organization located outside this state;  or(B)  paid in a different taxable year.(b)  The limitations provided by Subsections (a)(1) and (a)(2)(B) apply to foreign health maintenance organizations.|Added by Acts 2003, 78th Leg., ch. 209, Sec. 9A, eff. Jan. 1, 2004;  Acts 2003, 78th Leg., ch. 1276, Sec. 10A.207, eff. Sept. 1, 2003.|