2023 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 N. Enforcement › Section 843.461. Enforcement Actions

Sec. 843.461.  ENFORCEMENT ACTIONS.  (a)  After notice and opportunity for a hearing, the commissioner may:
(1)  suspend or revoke a certificate of authority issued to a health maintenance organization under this chapter;
(2)  impose sanctions under Chapter 82;
(3)  issue a cease and desist order under Chapter 83;  or
(4)  impose administrative penalties under Chapter 84.
(b)  The commissioner may take an enforcement action listed in Subsection (a) against a health maintenance organization if the commissioner finds that the health maintenance organization:
(1)  is operating in a manner that is:
(A)  significantly contrary to its basic organizational documents or health care plan; or
(B)  contrary to the manner described in and reasonably inferred from other information submitted under Section 843.078, 843.079, or 843.080;
(2)  issues an evidence of coverage or uses a schedule of charges for health care services that does not comply with the requirements of Sections 843.346, 1271.001-1271.005, 1271.007, 1271.151, 1271.152, and 1271.156, and Subchapters B, C, E, F, and G, Chapter 1271;
(3)  does not meet the requirements of Section 843.082(1);
(4)  provides a health care plan that does not provide or arrange for basic health care services, provides a limited health care service plan that does not provide or arrange for the plan's limited health care services, or provides a single health care service plan that does not provide or arrange for a single health care service;
(5)  cannot fulfill its obligation to provide:
(A)  health care services as required under its health care plan;
(B)  limited health care services as required under its limited health care service plan; or
(C)  a single health care service as required under its single health care service plan;
(6)  is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(7)  has not implemented the complaint system required by Section 843.251 in a manner to resolve reasonably valid complaints;
(8)  has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner or a person on behalf of the health maintenance organization has advertised or merchandised the health maintenance organization's services in an untrue, misrepresentative, misleading, deceptive, or unfair manner;
(9)  would be hazardous to its enrollees if it continued in operation;
(10)  has not complied substantially with:
(A)  this chapter or a rule adopted under this chapter; or
(B)  Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapter 222, 251, or 258, as applicable to a health maintenance organization, or Chapter 1271 or 1272 or a rule adopted under one of those provisions; or
(11)  has not taken corrective action the commissioner considers necessary to correct a failure to comply with this chapter, any applicable provision of this code, or any applicable rule or order of the commissioner not later than the 30th day after the date of notice of the failure or within any longer period specified in the notice and determined by the commissioner to be reasonable.
(c)  The commissioner may suspend or revoke a certificate of authority only after complying with this section.
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.052, eff. April 1, 2009.
Acts 2013, 83rd Leg., R.S., Ch. 161 (S.B. 1093), Sec. 11.001, eff. September 1, 2013.