reglab/housing_qa huggingface dataset:
TX Ins Code § 1272.056 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter B. Delegation Agreements|Section 1272.056. Compliance With Statutory and Regulatory Requirements

Sec. 1272.056.  COMPLIANCE WITH STATUTORY AND REGULATORY REQUIREMENTS.  A delegation agreement required by Section 1272.052 must provide that:(1)  the agreement does not limit in any way the health maintenance organization's authority or responsibility, including financial responsibility, to comply with each statutory or regulatory requirement;  and(2)  the delegated entity shall comply with each statutory or regulatory requirement relating to a function assumed by or carried out by the entity.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.057 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter B. Delegation Agreements|Section 1272.057. Examination by Commissioner

Sec. 1272.057.  EXAMINATION BY COMMISSIONER.  A delegation agreement required by Section 1272.052 must require the delegated entity to permit the commissioner to examine at any time any information the commissioner reasonably believes is relevant to:(1)  the financial solvency of the entity;  or(2)  the ability of the entity to meet the entity's responsibilities in connection with any function delegated to the entity by the health maintenance organization.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.058 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter B. Delegation Agreements|Section 1272.058. Information Relating to Delegated Third Party

Sec. 1272.058.  INFORMATION RELATING TO DELEGATED THIRD PARTY.  A delegation agreement required by Section 1272.052 must require the delegated entity to provide the license number of a delegated third party performing a function that requires:(1)  a license as a third-party administrator under Chapter 4151 or utilization review agent under Chapter 4201; or(2)  another license under this code or another insurance law of this state.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.003, eff. April 1, 2009.|
TX Ins Code § 1272.059 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter B. Delegation Agreements|Section 1272.059. Contracts With Delegated Third Party

Sec. 1272.059.  CONTRACTS WITH DELEGATED THIRD PARTY.  A  delegation agreement required by Section 1272.052 must provide that:(1)  any agreement under which the delegated entity directly or indirectly delegates a function required by this chapter, Chapter 843, 1271, or 1367, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507, including the handling of funds, if applicable, to a delegated third party must be in writing; and(2)  the delegated entity, in contracting with a delegated third party directly or through a third party, shall require the delegated third party to comply with the requirements of Section 1272.057 and any rules adopted by the commissioner implementing that section.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.074(g), eff. September 1, 2005.|
TX Ins Code § 1272.060 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter B. Delegation Agreements|Section 1272.060. Utilization Review

Sec. 1272.060.  UTILIZATION REVIEW.  A delegation agreement required by Section 1272.052 must provide that:(1)  enrollees shall receive notification at the time of enrollment of which entity is responsible for performing utilization review;(2)  the delegated entity or third party performing utilization review shall perform that review in accordance with Chapter 4201; and(3)  the delegated entity or third party shall forward utilization review decisions made by the entity or third party to the health maintenance organization on a monthly basis.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.004, eff. April 1, 2009.|
TX Ins Code § 1272.061 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter B. Delegation Agreements|Section 1272.061. Rights and Duties of Delegated Entity and Health Maintenance Organization

Sec. 1272.061.  RIGHTS AND DUTIES OF DELEGATED ENTITY AND HEALTH MAINTENANCE ORGANIZATION.  A delegation agreement required by Section 1272.052 must provide that the delegated entity acknowledges and agrees that:(1)  the health maintenance organization:(A)  is required to establish, operate, and maintain a health care delivery system, quality assurance system, provider credentialing system, and other systems and programs that meet statutory and regulatory standards;(B)  is directly accountable for compliance with those standards;  and(C)  is not precluded from contractually requesting that the delegated entity provide proof of financial viability;(2)  the role of another delegated entity with which the delegated entity subcontracts through a delegated third party is limited to performing certain delegated functions of the health maintenance organization, using standards that are approved by the health maintenance organization and that are in compliance with applicable statutes and rules and subject to the health maintenance organization's oversight and monitoring of the entity's performance;  and(3)  if the delegated entity fails to meet monitoring standards established to ensure that functions delegated or assigned to the entity under the delegation agreement are in full compliance with all statutory and regulatory requirements, the health maintenance organization may cancel delegation of any or all delegated functions.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.062 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter B. Delegation Agreements|Section 1272.062. Information to Be Provided by Delegated Entity to Health Maintenance Organization

Sec. 1272.062.  INFORMATION TO BE PROVIDED BY DELEGATED ENTITY TO HEALTH MAINTENANCE ORGANIZATION.  (a)  A delegation agreement required by Section 1272.052 must provide that:(1)  except as provided by Subsection (b), the delegated entity shall make available to the health maintenance organization samples of contracts with physicians and providers to ensure compliance with the contractual requirements described by Sections 1272.054 and 1272.055;  and(2)  the delegated entity shall provide to the health maintenance organization, in a format usable for audit purposes and not more frequently than quarterly unless otherwise specified in the delegation agreement, the data necessary for the health maintenance organization to comply with the department's reporting requirements with respect to any delegated functions performed under the delegation agreement, including:(A)  a summary describing the methods, including capitation, fee-for-service, or other risk arrangements, that the delegated entity used to pay the entity's physicians and providers, and including the percentage of physicians and providers paid for each payment category;(B)  the period that claims and debts for medical services owed by the delegated entity have been pending and the aggregate dollar amount of those claims and debts;(C)  information to enable the health maintenance organization to file claims for reinsurance, coordination of benefits, and subrogation, if required by the delegation agreement;  and(D)  documentation, except for information, documents, and deliberations related to peer review that are confidential or privileged under Subchapter A, Chapter 160, Occupations Code, that relates to:(i)  a regulatory agency's inquiry or investigation of the delegated entity or an individual physician or provider with whom the entity contracts that relates to an enrollee of the health maintenance organization;  and(ii)  the final resolution of a regulatory agency's inquiry or investigation.(b)  A delegation agreement may not require a delegated entity to make available to the health maintenance organization contractual provisions relating to financial arrangements with the entity's physicians and providers.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.063 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter B. Delegation Agreements|Section 1272.063. Enrollee Complaints

Sec. 1272.063.  ENROLLEE COMPLAINTS.  (a)  A delegation agreement required by Section 1272.052 must provide that:(1)  if the delegated entity receives a complaint that does not involve emergency care, the entity shall report the complaint to the health maintenance organization not later than the second business day after the date the entity receives the complaint;  and(2)  if the delegated entity receives a complaint involving emergency care, the entity shall immediately forward the complaint to the health maintenance organization.(b)  Subsection (a) does not prohibit a delegated entity from attempting to resolve a complaint.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.064 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter B. Delegation Agreements|Section 1272.064. Rules

Sec. 1272.064.  RULES.  The commissioner may adopt rules as necessary to implement this subchapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.101 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter C. Information Reporting to Delegated Entity|Section 1272.101. Applicability of Subchapter

Sec. 1272.101.  APPLICABILITY OF SUBCHAPTER.  This subchapter does not apply to a group model health maintenance organization, as defined by Section 843.111.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.102 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter C. Information Reporting to Delegated Entity|Section 1272.102. Reporting Required

Sec. 1272.102.  REPORTING REQUIRED.  (a)  The commissioner shall determine the information a health maintenance organization shall provide to a delegated entity with which the health maintenance organization has entered into a delegation agreement.(b)  The information must include:(1)  for each enrollee who is eligible or assigned to receive services from the delegated entity:(A)  the enrollee's name, birth date or social security number, age, and sex;(B)  the benefit plan and any riders to that plan that are applicable to the enrollee;  and(C)  the enrollee's employer;(2)  the name and birth date or social security number of each enrollee added or terminated since the health maintenance organization last provided the information;(3)  if the health maintenance organization pays any claims on behalf of the delegated entity, a summary of the number and amount of:(A)  claims paid during the previous reporting period;  and(B)  pharmacy prescriptions paid for each enrollee during the previous reporting period for which the delegated entity has taken partial risk;(4)  information that enables the delegated entity to file claims for reinsurance, coordination of benefits, and subrogation;(5)  patient complaint data that relates to the delegated entity;(6)  detailed risk-pool data, reported quarterly and on settlement;(7)  if hospital or facility costs impact the delegated entity's costs, the percent of premium attributable to hospital or facility costs, reported quarterly;  and(8)  if there are changes in hospital or facility contracts with the health maintenance organization, the projected impact of those changes on the percent of premium attributable to hospital and facility costs during the 30-day period following those changes.(c)  Notwithstanding Subsection (b)(3), a delegated entity may, on request, receive additional nonproprietary information regarding claims paid by a health maintenance organization on behalf of the entity.(d)  A health maintenance organization shall provide information required under Subsections (b)(1)-(5) in standard electronic format at least monthly unless the delegation agreement provides otherwise.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.103 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter C. Information Reporting to Delegated Entity|Section 1272.103. Rules

Sec. 1272.103.  RULES.  The commissioner may adopt rules as necessary to implement this subchapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.151 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter D. Reserve Requirements|Section 1272.151. Applicability of Subchapter

Sec. 1272.151.  APPLICABILITY OF SUBCHAPTER.  This subchapter does not apply to a group model health maintenance organization, as defined by Section 843.111.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.152 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter D. Reserve Requirements|Section 1272.152. General Reserve Requirements

Sec. 1272.152.  GENERAL RESERVE REQUIREMENTS.  (a)  A delegated network shall maintain reserves adequate for the liabilities and risks assumed by the network, as computed in accordance with accepted standards, practices, and procedures relating to the liabilities and risks for which the reserves are maintained, including known and unknown components and anticipated expenses of providing benefits or services.(b)  Except as provided by Sections 1272.153 and 1272.154, a delegated network shall maintain reserves as described by Subsection (c) only with respect to the portion of services assumed under the delegation agreement that is outside the scope of the network's license for medical care or hospital or other institutional services, as applicable.(c)  A delegated network shall maintain financial reserves equal to the greater of:(1)  80 percent of the amount of liabilities and risks for which reserves must be maintained under this subchapter and that have been incurred but not paid by the network;  or(2)  an amount equal to two months of the premium amount assumed by the network for services with respect to which reserves must be maintained under this subchapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.153 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter D. Reserve Requirements|Section 1272.153. Reserve Requirements for Medical Care and Hospital or Institutional Services

Sec. 1272.153.  RESERVE REQUIREMENTS FOR MEDICAL CARE AND HOSPITAL OR INSTITUTIONAL SERVICES.  A delegated network that assumes under a delegation agreement both medical care and hospital or institutional services shall maintain reserves adequate to cover the liabilities and risks associated with medical care or hospital or institutional services, whichever category of services is allocated the largest portion of the premium by the health maintenance organization.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.154 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter D. Reserve Requirements|Section 1272.154. Reserve Requirements for Prescription Drugs

Sec. 1272.154.  RESERVE REQUIREMENTS FOR PRESCRIPTION DRUGS.  A delegated network that assumes financial risk for medical care or hospital or institutional services and for prescription drugs, as defined by Section 551. 003, Occupations Code, shall maintain, in addition to any other reserves required under this subchapter, reserves adequate to cover the liabilities and risks associated with the prescription drug benefits.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.155 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter D. Reserve Requirements|Section 1272.155. Form of Reserves

Sec. 1272.155.  FORM OF RESERVES.  The reserves required under this subchapter must be:(1)  secured by and consist only of United States legal tender or bonds of the United States or this state;(2)  held at a financial institution in this state that is chartered by the United States or this state;  and(3)  held in trust for, for the benefit of, or to provide health care services to enrollees under the delegation agreement.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.156 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter D. Reserve Requirements|Section 1272.156. Escrow Account

Sec. 1272.156.  ESCROW ACCOUNT.  (a)  A delegated network required to maintain reserves under this subchapter shall establish an escrow account to pay claims and deposit the reserves into the escrow account on:(1)  notification of the network's intent to terminate or refuse to renew a contract under which the network assumed liabilities and risks from a health maintenance organization;  or(2)  modification of a contract under which the network assumed liabilities and risks from a health maintenance organization if the modified contract eliminates those liabilities and risks.(b)  The delegated network shall notify the commissioner on establishing an escrow account under this section.(c)  On the 271st day after the date the reserves are deposited into the escrow account, the delegated network is entitled to the release of funds remaining in escrow.  Funds released from the escrow account shall be distributed to each individual who contributed to the reserves deposited into the account in proportion to the individual's total contribution.(d)  The commissioner shall take any action necessary to ensure the release of funds remaining in escrow after the date specified by Subsection (c).|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.201 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.201. Applicability of Subchapter

Sec. 1272.201.  APPLICABILITY OF SUBCHAPTER.  This subchapter does not apply to a group model health maintenance organization, as defined by Section 843.111.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.202 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.202. Notice of Noncompliance or Hazardous Operating Condition

Sec. 1272.202.  NOTICE OF NONCOMPLIANCE OR HAZARDOUS OPERATING CONDITION.  (a)  If a health maintenance organization becomes aware of information that indicates a delegated entity with which the health maintenance organization has entered into a delegation agreement is not operating in accordance with the agreement or is operating in a condition that renders continuing the entity's business hazardous to the enrollees, the health maintenance organization shall in writing:(1)  notify the entity of those findings;  and(2)  request a written explanation and documentation supporting that explanation of the entity's apparent noncompliance or the existence of the hazardous condition.(b)  A health maintenance organization shall provide to the commissioner a copy of each notice and request submitted to a delegated entity under this section and each response or other documentation the health maintenance organization receives or generates in response to the notice and request.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.203 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.203. Response to Notice

Sec. 1272.203.  RESPONSE TO NOTICE.  A delegated entity shall respond in writing to a request from a health maintenance organization under Section 1272.202 not later than the 30th day after the date the entity receives the request.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1272.204 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle C - Managed Care|Chapter 1272 - Delegation of Certain Functions by Health Maintenance Organization|Subchapter E. Compliance|Section 1272.204. Cooperation of Health Maintenance Organization

Sec. 1272.204.  COOPERATION OF HEALTH MAINTENANCE ORGANIZATION.  A health maintenance organization shall cooperate with a delegated entity to correct a failure by the entity to comply with the department's regulatory requirements relating to:(1)  a function delegated to the entity by the health maintenance organization;  or(2)  a matter necessary for the health maintenance organization to ensure compliance with each statutory or regulatory requirement.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|