reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter D. Certain Benefits Required › Section 1271.159. Non-Network Emergency Medical Services Provider

Sec. 1271.159.  NON-NETWORK EMERGENCY MEDICAL SERVICES PROVIDER.  (a)  In this section, "emergency medical services provider" has the meaning assigned by Section 773.003, Health and Safety Code, except that the term does not include an air ambulance.
(b)  Except as provided by Subsection (c), a health maintenance organization shall pay for a covered health care service performed for, or a covered supply or covered transport related to that service provided to, an enrollee by a non-network emergency medical services provider at:
(1)  if the political subdivision has submitted the rate to the department under Section 38.006, the rate set, controlled, or regulated by the political subdivision in which:
(A)  the service originated; or
(B)  the transport originated if transport is provided; or
(2)  if the political subdivision has not submitted the rate to the department, the lesser of:
(A)  the provider's billed charge; or
(B)  325 percent of the current Medicare rate, including any applicable extenders and modifiers.
(c)  A health maintenance organization shall adjust a payment required by Subsection (b)(1) each plan year by increasing the payment by the lesser of the Medicare Inflation Index or 10 percent of the provider's previous calendar year rates.
(d)  The health maintenance organization shall make a payment required by this section directly to the provider not later than, as applicable:
(1)  the 30th day after the date the health maintenance organization receives an electronic clean claim as defined by Section 843.336 for those services that includes all information necessary for the health maintenance organization to pay the claim; or
(2)  the 45th day after the date the health maintenance organization receives a nonelectronic clean claim as defined by Section 843.336 for those services that includes all information necessary for the health maintenance organization to pay the claim.
(e)  A non-network emergency medical services provider or a person asserting a claim as an agent or assignee of the provider may not bill an enrollee receiving a health care service or supply or transport described by Subsection (b) in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee's health care plan that is based on:
(1)  the amount initially determined payable by the health maintenance organization; or
(2)  if applicable, a modified amount as determined under the health maintenance organization's internal appeal process.
(f)  This section may not be construed to require the imposition of a penalty under Section 843.342.
(g)  This section expires September 1, 2025.
Added by Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 3, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter E. Choice of Primary Care Physician for Certain Enrollees › Section 1271.201. Designation of Specialist as Primary Care Physician

Sec. 1271.201.  DESIGNATION OF SPECIALIST AS PRIMARY CARE PHYSICIAN.  (a)  An evidence of coverage must provide that an enrollee with a chronic, disabling, or life-threatening illness may apply to the health maintenance organization's medical director to use a nonprimary care physician specialist as the enrollee's primary care physician.
(b)  The application must:
(1)  include information specified by the health maintenance organization, including certification of the medical need;  and
(2)  be signed by the enrollee and the nonprimary care physician specialist interested in serving as the enrollee's primary care physician.
(c)  To be eligible to serve as the enrollee's primary care physician, a physician specialist must:
(1)  meet the health maintenance organization's requirements for primary care physician participation;  and
(2)  agree to accept the responsibility to coordinate all of the enrollee's health care needs.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter E. Choice of Primary Care Physician for Certain Enrollees › Section 1271.202. Appeal

Sec. 1271.202.  APPEAL.  If a health maintenance organization denies a request under Section 1271.201, the enrollee may appeal the decision through the health maintenance organization's established complaint and appeals process.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter E. Choice of Primary Care Physician for Certain Enrollees › Section 1271.203. Effective Date of Designation

Sec. 1271.203.  EFFECTIVE DATE OF DESIGNATION.  (a)  The effective date of the designation of a nonprimary care physician specialist as an enrollee's primary care physician under Section 1271.201 may not be applied retroactively.
(b)  A health maintenance organization may not reduce the amount of compensation owed to the original primary care physician for services provided before the date of the new designation.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter F. Schedule of Charges › Section 1271.251. Approval of Formula or Method for Computing Schedule of Charges

Sec. 1271.251.  APPROVAL OF FORMULA OR METHOD FOR COMPUTING SCHEDULE OF CHARGES.  (a)  The formula or method for computing the schedule of charges for enrollee coverage for health care services must be filed with the commissioner before the formula or method is used in conjunction with a health care plan.
(b)  The formula or method must be established in accordance with actuarial principles for the various categories of enrollees.  The filing of the method or formula must contain:
(1)  a statement by a qualified actuary that certifies that the formula or method is appropriate;  and
(2)  supporting information that the commissioner considers adequate.
(c)  The formula or method must produce charges that are not excessive, inadequate, or unfairly discriminatory.  Benefits must be reasonable with respect to the rates produced by the formula or method.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter F. Schedule of Charges › Section 1271.252. Consideration of Individual Health Status Prohibited

Sec. 1271.252.  CONSIDERATION OF INDIVIDUAL HEALTH STATUS PROHIBITED.  The charges resulting from the application of a formula or method described by Section 1271.251 may not be altered for an individual enrollee based on the status of that enrollee's health.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter F. Schedule of Charges › Section 1271.253. Information Required by Commissioner

Sec. 1271.253.  INFORMATION REQUIRED BY COMMISSIONER.  The commissioner may require the submission of any relevant information the commissioner considers necessary in determining whether to approve or disapprove a filing under this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter G. Continuation of Coverage, Conversion Contracts, and Renewal › Section 1271.301. Entitlement to Continuation of Group Coverage

Sec. 1271.301.  ENTITLEMENT TO CONTINUATION OF GROUP COVERAGE.  (a)  In this section, "involuntary termination for cause" does not include termination for any health-related reason.
(b)  A health maintenance organization shall provide a group coverage continuation privilege as required by and subject to the eligibility provisions of this subchapter.
(c)  An enrollee is entitled to continue group coverage as provided by this subchapter if:
(1)  the enrollee's coverage under a group contract is terminated for any reason except involuntary termination for cause;  and
(2)  the enrollee for at least three consecutive months immediately before the termination of coverage has been continuously covered under the group contract and under any previous group contract providing similar services and benefits that the current group contract replaced.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter G. Continuation of Coverage, Conversion Contracts, and Renewal › Section 1271.302. Request for Continued Coverage; Deadline

Sec. 1271.302.  REQUEST FOR CONTINUED COVERAGE; DEADLINE.  An enrollee must provide to the employer or group contract holder a written notice of election to continue group coverage under this subchapter not later than the 60th day after the later of:
(1)  the date the group coverage would otherwise terminate; or
(2)  the date the enrollee is given notice of the right of continuation by the employer or group contract holder.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 550 (S.B. 1771), Sec. 5, eff. June 19, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter G. Continuation of Coverage, Conversion Contracts, and Renewal › Section 1271.303. Payment for Continued Coverage

Sec. 1271.303.  PAYMENT FOR CONTINUED COVERAGE.  (a)  An enrollee electing continuation of group coverage must pay to the employer or group contract holder the amount of contribution required by the employer or group contract holder, plus an amount equal to two percent of the group rate for the coverage being continued under the group contract.
(b)  The enrollee must make the payment not later than the 45th day after the initial election for coverage and on the due date of each payment thereafter.  Following the first payment made after the initial election for coverage, the payment of any other premium shall be considered timely if made by the 30th day after the date on which payment is due.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 550 (S.B. 1771), Sec. 6, eff. June 19, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter G. Continuation of Coverage, Conversion Contracts, and Renewal › Section 1271.304. Termination of Continued Coverage

Sec. 1271.304.  TERMINATION OF CONTINUED COVERAGE.  Group continued coverage under this subchapter may not terminate until the earliest of:
(1)  the date the maximum continuation period provided by law would end, which is:
(A)  for any enrollee not eligible for continuation coverage under Title X, Consolidated Omnibus Budget Reconciliation Act of 1985 (29 U.S.C. Section 1161 et seq.) (COBRA), the end of the nine-month period after the date the election to continue coverage is made; or
(B)  for any enrollee eligible for continuation coverage under COBRA, six additional months following any period of continuation provided under that statute;
(2)  the date on which failure to make timely payments terminates coverage;
(3)  the date on which the enrollee is covered for similar services and benefits by any other plan or program, including a hospital, surgical, medical, or major medical expense insurance policy, hospital or medical service subscriber contract, or medical practice or other prepayment plan; or
(4)  the date on which the group coverage terminates in its entirety.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 550 (S.B. 1771), Sec. 7, eff. June 19, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter G. Continuation of Coverage, Conversion Contracts, and Renewal › Section 1271.306. Conversion Contracts

Sec. 1271.306.  CONVERSION CONTRACTS.  (a)  A health maintenance organization may offer to each enrollee a conversion contract.
(b)  A health maintenance organization shall issue the conversion contract without evidence of insurability if written application for the contract and payment of the first premium are made not later than the 31st day after the date of termination of coverage.
(c)  A conversion contract must meet the minimum standards for services and benefits for conversion contracts.  The commissioner shall adopt rules to prescribe the minimum standards for services and benefits applicable to conversion contracts.
(d)  The premium for a conversion contract shall be determined in accordance with the health maintenance organization's premium rates for coverage provided under the group contract or plan.  The premium may be based on the geographic location of each person to be covered and must be based on the type of conversion contract and the coverage provided by the contract.  The premium may not exceed 200 percent of the premium rates for the same coverage provided under a group contract or plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter G. Continuation of Coverage, Conversion Contracts, and Renewal › Section 1271.307. Renewability of Coverage: Individual Health Care Plans and Conversion Contracts

Sec. 1271.307.  RENEWABILITY OF COVERAGE:  INDIVIDUAL HEALTH CARE PLANS AND CONVERSION CONTRACTS.  (a)  In this section, "individual health care plan" has the meaning assigned by Section 1271.004.
(b)  An individual health care plan or a conversion contract that provides health care services to an enrollee is renewable at the option of the enrollee.  A health maintenance organization may decline to renew an individual health care plan or conversion contract only:
(1)  for failure to pay premiums or contributions in accordance with the terms of the plan or because the issuer of the plan has not received timely premium payments;
(2)  for fraud or intentional misrepresentation;
(3)  because the health maintenance organization ceases to offer coverage in the individual market in accordance with rules established by the commissioner;
(4)  because the enrollee no longer resides or works in the area in which the health maintenance organization is authorized to provide coverage, if coverage under the plan is terminated uniformly for this reason without regard to any factor related to the health status of a covered enrollee;  or
(5)  in accordance with applicable federal law, including regulations.
(c)  The commissioner may adopt rules necessary to implement this section and to meet the minimum requirements of federal law, including regulations.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 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 A. General Provisions › Section 1272.002. Compliance of Limited Provider Network or Delegated Entity With Certain Legal Requirements

Sec. 1272.002.  COMPLIANCE OF LIMITED PROVIDER NETWORK OR DELEGATED ENTITY WITH CERTAIN LEGAL REQUIREMENTS.  A limited provider network or delegated entity shall comply with each statutory or regulatory requirement that relates to a function assumed by or carried out by the network or entity under this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 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 1272.051. Applicability of Subchapter

Sec. 1272.051.  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.
2023 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 1272.052. Delegation Agreement Required

Sec. 1272.052.  DELEGATION AGREEMENT REQUIRED.  (a)  A health maintenance organization that delegates a function required by this chapter, Chapter 843, 1271, or 1367, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507, shall execute a written delegation agreement with the entity to which the function is delegated.
(b)  The health maintenance organization shall file the delegation agreement with the department not later than the 30th day after the date the agreement is executed.
(c)  The parties to the delegation agreement shall determine which party bears the expense of complying with a requirement of this subchapter, including the cost of an examination required by the department under Subchapter B, Chapter 401, if applicable.
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(f), eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.002, eff. April 1, 2009.
2023 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 1272.053. Monitoring Plan

Sec. 1272.053.  MONITORING PLAN.  A delegation agreement required by Section 1272.052 must establish a monitoring plan that:
(1)  allows the health maintenance organization to monitor compliance with the minimum solvency requirements established under Subchapter D, if applicable;  and
(2)  includes:
(A)  a description of financial practices that will ensure that the delegated entity tracks and reports liabilities that have been incurred but not reported;
(B)  a summary of the total amount paid by the entity to physicians and providers on a monthly basis;  and
(C)  a summary of complaints from physicians, providers, and enrollees regarding delays in payment or nonpayment of claims, including the status of each complaint, on a monthly basis.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 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 1272.054. Requirements for Termination Without Cause

Sec. 1272.054.  REQUIREMENTS FOR TERMINATION WITHOUT CAUSE.  A delegation agreement required by Section 1272.052 must provide that the agreement cannot be terminated without cause by the delegated entity or the health maintenance organization unless the party terminating the agreement provides written notice before the 90th day before the termination date.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 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 1272.055. Collection of Payments

Sec. 1272.055.  COLLECTION OF PAYMENTS.  A delegation agreement required by Section 1272.052 must prohibit the delegated entity and the physicians and providers with whom the entity has contracted from billing or attempting to collect from an enrollee under any circumstance, including the insolvency of the health maintenance organization or entity, payments for covered services other than authorized copayments and deductibles.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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 1272.205. Examination by Department; Report

Sec. 1272.205.  EXAMINATION BY DEPARTMENT;  REPORT.  (a)  On receipt of a notice under Section 1272.202 or if complaints are filed with the department, the department may conduct an examination regarding:
(1)  any matter contained in the notice;  and
(2)  any other matter relating to the financial solvency of the delegated entity or the entity's ability to meet the entity's responsibilities in connection with a function delegated to the entity by the health maintenance organization.
(b)  Except as provided by Subsection (c), the department, on completion of an examination under this section, shall report to the delegated entity and the health maintenance organization:
(1)  the results of the examination;  and
(2)  any action the department determines is necessary to ensure that:
(A)  the health maintenance organization meets the health maintenance organization's responsibilities under this code, any other insurance laws of this state, and rules adopted by the commissioner;  and
(B)  the entity is able to meet the entity's responsibilities in connection with a function delegated to the entity by the health maintenance organization.
(c)  The department may not report to the health maintenance organization information relating to fee schedules, prices, or cost of care or other information not relevant to the monitoring plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 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 1272.206. Response to Department Report; Corrective Plan

Sec. 1272.206.  RESPONSE TO DEPARTMENT REPORT;  CORRECTIVE PLAN.  The delegated entity and health maintenance organization shall respond to the department's report under Section 1272.205(b) and submit a corrective plan to the department not later than the 30th day after the date of receipt of the report.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 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 1272.207. Request for Corrective Action

Sec. 1272.207.  REQUEST FOR CORRECTIVE ACTION.  The department may request at any time that a delegated entity take corrective action to comply with the department's statutory and regulatory requirements that:
(1)  relate to a function delegated by the health maintenance organization to the entity;  or
(2)  are necessary to ensure the health maintenance organization's compliance with each statutory or regulatory requirement.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.