reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter E. Provision of Coverage › Section 846.209. Written Statement of Denial, Cancellation, or Refusal to Renew

Sec. 846.209.  WRITTEN STATEMENT OF DENIAL, CANCELLATION, OR REFUSAL TO RENEW.  Denial by a multiple employer welfare arrangement of an application for coverage from an employer or cancellation of or refusal to renew must:
(1)  be in writing;  and
(2)  state the reason or reasons for the denial, cancellation, or refusal to renew.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter F. Participation in Coverage › Section 846.251. Participation Criteria

Sec. 846.251.  PARTICIPATION CRITERIA.  Participation criteria may not be based on health status related factors.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter F. Participation in Coverage › Section 846.252. Coverage Requirements

Sec. 846.252.  COVERAGE REQUIREMENTS.  (a)  A multiple employer welfare arrangement:
(1)  may refuse to provide coverage to an employer in accordance with the arrangement's underwriting standards and criteria;
(2)  shall accept or reject the entire group of individuals who meet the participation criteria and who choose coverage;  and
(3)  may exclude only those employees or dependents who have declined coverage.
(b)  On issuance of coverage to an employer, each multiple employer welfare arrangement shall provide coverage to the employees who meet the participation criteria without regard to an individual's health status related factors.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter F. Participation in Coverage › Section 846.253. Prohibition on Exclusion of Eligible Employee or Dependent

Sec. 846.253.  PROHIBITION ON EXCLUSION OF ELIGIBLE EMPLOYEE OR DEPENDENT.  A multiple employer welfare arrangement may not exclude an employee who meets the participation criteria or an eligible dependent, including a late-participating employee or dependent, who would otherwise be covered.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter F. Participation in Coverage › Section 846.254. Written Notice to Employees Covered

Sec. 846.254.  WRITTEN NOTICE TO EMPLOYEES COVERED.  A multiple employer welfare arrangement, in connection with an employee welfare benefit plan, shall provide to each participating employee covered by the plan a written notice at the time the employee's coverage becomes effective that states that:
(1)  individuals covered by the plan are only partially insured;  and
(2)  if the plan or the arrangement does not ultimately pay medical expenses that are eligible for payment under the plan for any reason, the participating employer or its participating employee covered by the plan may be liable for those expenses.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter F. Participation in Coverage › Section 846.255. Declining Coverage

Sec. 846.255.  DECLINING COVERAGE.  (a)  A multiple employer welfare arrangement shall obtain a written waiver from each employee who meets the participation criteria and declines coverage under a health plan offered to an employer.  The waiver must ensure that the employee was not induced or pressured to decline coverage because of the employee's health status related factors.
(b)  A multiple employer welfare arrangement may not provide coverage to an employer or the employees of an employer if the arrangement or an agent for the arrangement knows that the employer has induced or pressured an employee who meets the participation criteria or a dependent of the employee to decline coverage because of that individual's health status related factors.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter F. Participation in Coverage › Section 846.256. Minimum Contribution or Participation Requirements

Sec. 846.256.  MINIMUM CONTRIBUTION OR PARTICIPATION REQUIREMENTS.  (a)  A multiple employer welfare arrangement may require an employer to meet minimum contribution or participation requirements as a condition of issuance and renewal of coverage in accordance with the terms of the arrangement's plan document.
(b)  The minimum contribution and participation requirements must be stated in the plan document and must be applied uniformly to each employer offered or issued coverage by the multiple employer welfare arrangement in this state.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter F. Participation in Coverage › Section 846.257. Enrollment; Waiting Period

Sec. 846.257.  ENROLLMENT;  WAITING PERIOD.  (a)  The initial enrollment period for employees meeting the participation criteria must be at least 31 days, with a 31-day annual open enrollment period.  The enrollment period must consist of an entire calendar month, beginning on the first day of the month and ending on the last day of the month.  If the month is February, the period must last through March 2.
(b)  A multiple employer welfare arrangement may establish a waiting period.
(c)  A new employee who meets the participation criteria may not be denied coverage if the application for coverage is received by the multiple employer welfare arrangement not later than the 31st day after the later of:
(1)  the date on which the employment begins;  or
(2)  the date on which the waiting period established under Subsection (b) expires.
(d)  If dependent coverage is offered to participating employees under the terms of a multiple employer welfare arrangement's plan document:
(1)  the initial enrollment period for the dependents must be at least 31 days, with a 31-day annual open enrollment period;  and
(2)  a dependent of a new employee meeting the participation criteria established by the arrangement may not be denied coverage if the application for coverage is received by the arrangement not later than the 31st day after the later of:
(A)  the date on which the employment begins;
(B)  the date on which the waiting period established under Subsection (b) expires;  or
(C)  the date on which the dependent becomes eligible for enrollment.
(e)  A late-participating employee or dependent may be excluded from coverage until the next annual open enrollment period and may be subject to a one-year preexisting condition provision as described by Section 846.202.  The period during which a preexisting condition provision applies may not exceed 18 months after the date of the initial application.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter F. Participation in Coverage › Section 846.258. Coverage for Newborn Children

Sec. 846.258.  COVERAGE FOR NEWBORN CHILDREN.  (a)  A multiple employer welfare arrangement's plan document may not limit or exclude initial coverage of a newborn child of a participating employee.
(b)  Coverage of a newborn child of a participating employee under this section ends on the 32nd day after the date of the child's birth unless:
(1)  children are eligible for coverage under the multiple employer welfare arrangement's plan document;  and
(2)  not later than the 31st day after the date of birth, the arrangement receives:
(A)  notice of the birth;  and
(B)  any required additional premium.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.219(a), eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter F. Participation in Coverage › Section 846.259. Coverage for Adopted Children

Sec. 846.259.  COVERAGE FOR ADOPTED CHILDREN.  (a)  This section applies only if children are eligible for coverage under the terms of a multiple employer welfare arrangement's plan document.
(b)  A multiple employer welfare arrangement plan document may not limit or exclude initial coverage of an adopted child of a participating employee.  A child is considered to be the child of a participating employee if the participating employee is a party to a suit in which the employee seeks to adopt the child.
(c)  An adopted child of a participating employee may be enrolled, at the employee's option, not later than the 31st day after:
(1)  the date the employee becomes a party to a suit in which the employee seeks to adopt the child;  or
(2)  the date the adoption becomes final.
(d)  Coverage of an adopted child of a participating employee under this section ends unless the multiple employer welfare arrangement receives notice of the adoption and any required additional premiums not later than the 31st day after:
(1)  the date the participating employee becomes a party to a suit in which the employee seeks to adopt the child;  or
(2)  the date the adoption becomes final.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.219(b), eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter F. Participation in Coverage › Section 846.260. Limiting Age Applicable to Unmarried Child

Sec. 846.260.  LIMITING AGE APPLICABLE TO UNMARRIED CHILD.  If children are eligible for coverage under the terms of a multiple employer welfare arrangement's plan document, any limiting age applicable to an unmarried child of an enrollee is 25 years of age.
Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.219(c), eff. Sept. 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter G. Marketing › Section 846.301. Marketing Requirements

Sec. 846.301.  MARKETING REQUIREMENTS.  On request, each employer purchasing a health benefit plan shall be given a summary of the plans for which the employer is eligible.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter G. Marketing › Section 846.302. Additional Reporting Requirements

Sec. 846.302.  ADDITIONAL REPORTING REQUIREMENTS.  The department may require periodic reports by multiple employer welfare arrangements and agents regarding the health benefit plans issued by the arrangements.  The reporting requirements must comply with federal law and regulations.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 846 - Multiple Employer Welfare Arrangements › Subchapter G. Marketing › Section 846.303. Applicability to Third-Party Administrator

Sec. 846.303.  APPLICABILITY TO THIRD-PARTY ADMINISTRATOR.  If a multiple employer welfare arrangement enters into an agreement with a third-party administrator to provide administrative, marketing, or other services related to offering health benefit plans to employers in this state, the third-party administrator is subject to this chapter.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 847 - Health Care Quality Assurance › Section 847.001. Short Title

Sec. 847.001.  SHORT TITLE.  This chapter may be cited as the Health Care Quality Assurance Act.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 1, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 847 - Health Care Quality Assurance › Section 847.002. Legislative Findings; Purposes

Sec. 847.002.  LEGISLATIVE FINDINGS; PURPOSES.  The legislature finds that to ensure enrollees high quality care, many health benefit plan issuers voluntarily undergo a rigorous accreditation process conducted by nationally recognized accreditation organizations.  To maintain accreditation, these health benefit plan issuers are subject to continuing review of their processes and standards.  The legislature recognizes that many of these processes and standards are also reviewed by state agencies, resulting in increased agency costs and increased health benefit plan administrative costs.  The purpose of this chapter is to allow appropriate recognition of accreditation by nationally recognized accreditation organizations and to foster coordination among state agencies in order to:
(1)  help make health benefit plan coverage more affordable for consumers; and
(2)  eliminate duplication of effort by both health benefit plan issuers and state agencies.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 1, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 847 - Health Care Quality Assurance › Section 847.003. Definitions

Sec. 847.003.  DEFINITIONS.  In this chapter:
(1)  "Commission" means the Health and Human Services Commission.
(2)  "Health benefit plan" means an individual, group, blanket, or franchise insurance policy, a certificate issued under a group policy, a group hospital service contract, or an individual or group subscriber contract or evidence of coverage issued by a health maintenance organization that provides benefits for health care services.  The term does not include:
(A)  accident-only or disability income insurance coverage or a combination of accident-only and disability income insurance coverage;
(B)  credit-only insurance coverage;
(C)  disability insurance coverage;
(D)  Medicare services under a federal contract;
(E)  Medicare supplement and Medicare Select benefit plans regulated in accordance with federal law;
(F)  long-term care coverage or benefits, nursing home care coverage or benefits, home health care coverage or benefits, community-based care coverage or benefits, or any combination of those coverages or benefits;
(G)  workers' compensation insurance coverage or similar insurance coverage;
(H)  coverage provided through a jointly managed trust authorized under 29 U.S.C. Section 141 et seq. that contains a plan of benefits for employees that is negotiated in a collective bargaining agreement governing wages, hours, and working conditions of the employees that is authorized under 29 U.S.C. Section 157;
(I)  hospital indemnity or other fixed indemnity insurance coverage;
(J)  reinsurance contracts issued on a stop-loss, quota-share, or similar basis;
(K)  short-term major medical contracts;
(L)  liability insurance coverage, including general liability insurance coverage and automobile liability insurance coverage, and coverage issued as a supplement to liability insurance coverage, including automobile medical payment insurance coverage;
(M)  coverage for on-site medical clinics;
(N)  coverage that provides other limited benefits specified by federal regulations;
(O)  coverage that provides limited scope dental or vision benefits; or
(P)  other coverage that:
(i)  is similar to the coverage described by this subdivision under which benefits for medical care are secondary or incidental to other coverage benefits; and
(ii)  is specified by federal regulations.
(3)  "National accreditation organization" means:
(A)  the Accreditation Association for Ambulatory Health Care;
(B)  the Joint Commission on Accreditation of Healthcare Organizations;
(C)  the National Committee for Quality Assurance;
(D)  the American Accreditation HealthCare Commission ("URAC"); or
(E)  any other national accreditation entity recognized by rules jointly adopted by the commissioner of insurance and the executive commissioner of the commission.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 1, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 847 - Health Care Quality Assurance › Section 847.004. Applicability of Chapter

Sec. 847.004.  APPLICABILITY OF CHAPTER.  This chapter applies only to an entity that issues a health benefit plan and that holds a license or certificate of authority issued by the commissioner and provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a health maintenance organization operating under Chapter 843;
(4)  an approved nonprofit health corporation that holds a certificate of authority issued by the commissioner under Chapter 844;
(5)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(6)  a stipulated premium company operating under Chapter 884;
(7)  a fraternal benefit society operating under Chapter 885; or
(8)  a reciprocal exchange operating under Chapter 942.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 1, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 847 - Health Care Quality Assurance › Section 847.005. Presumed Compliance With Certain Statutory and Regulatory Requirements

Sec. 847.005.  PRESUMED COMPLIANCE WITH CERTAIN STATUTORY AND REGULATORY REQUIREMENTS.  (a)  A health benefit plan issuer is presumed to be in compliance with state statutory and regulatory requirements if:
(1)  the health benefit plan issuer has received nonconditional accreditation by a national accreditation organization; and
(2)  the national accreditation organization's accreditation requirements are the same, substantially similar to, or more stringent than the department's statutory or regulatory requirements.
(b)  A health benefit plan issuer that offers a Medicare Advantage coordinated care plan under a contract with the federal Centers for Medicare and Medicaid Services is presumed to be in compliance with any state statutory and regulatory requirements that are the same, substantially similar to, or more stringent than the requirements for Medicare Advantage coordinated care plans, as determined by the commissioner.
(c)  If the department determines that a health benefit plan issuer is in compliance with a state statutory or regulatory requirement, the commission may presume that a Medicaid or state child health plan program managed care plan offered by a health benefit plan issuer under contract with the commission is in compliance with any contractual Medicaid or state child health plan program managed care plan requirement that is the same as, substantially similar to, or more stringent than the state statutory or regulatory requirement, as determined by the commission.
(d)  The commissioner may take appropriate action, including imposition of sanctions under Chapter 82, against a health benefit plan issuer who is presumed under Subsection (a), (b), or (c) to be in compliance with state statutory and regulatory requirements but does not maintain compliance with the same, substantially similar, or more stringent requirements applicable to the issuer under Subsection (a), (b), or (c).
(e)  The department shall monitor and analyze periodically as prescribed by rule by the commissioner updates and amendments made to national accreditation standards as necessary to ensure that those standards remain the same, substantially similar to, or more stringent than the department's statutory or regulatory requirements.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 1, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 847 - Health Care Quality Assurance › Section 847.006. Filing of Accreditation Report; Confidentiality Requirements

Sec. 847.006.  FILING OF ACCREDITATION REPORT; CONFIDENTIALITY REQUIREMENTS.  (a)  The commissioner may require a health benefit plan issuer to submit to the commissioner the accreditation report issued by the national accreditation organization.
(b)  An accreditation report submitted under Subsection (a) is proprietary and confidential information under Chapter 552, Government Code, and is not subject to subpoena.  The commissioner shall limit the disclosure of the accreditation report to those department employees who need the accreditation report to perform the duties of their job.  A department employee may not further disclose the accreditation report.
(c)  The national accreditation organization recommendations summary results are not proprietary information and are subject to public disclosure under Chapter 552, Government Code.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 1, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 847 - Health Care Quality Assurance › Section 847.007. Duties of Commissioner of Insurance

Sec. 847.007.  DUTIES OF COMMISSIONER OF INSURANCE.  (a)  In conducting an examination of a health benefit plan issuer, the commissioner:
(1)  shall accept the accreditation report submitted by the health benefit plan issuer as a prima facie demonstration of the issuer's compliance with the processes and standards for which the issuer has received accreditation; and
(2)  may adopt relevant findings in a health benefit plan issuer's accreditation report in the examination report if the accreditation report complies with applicable state and federal requirements regarding the nondisclosure of proprietary and confidential information and personal health information.
(b)  Subsection (a) does not apply to any process or standard of a health benefit plan issuer that is not covered as part of the issuer's accreditation.  This section does not set minimum quality standards but operates only as a replacement of duplicate requirements.
(c)  The commissioner may by rule determine the application of compliance with national accreditation requirements by a delegated entity, delegated third party, or utilization review agent to compliance by the health benefit plan issuer that contracts with the delegated entity, delegated third party, or agent.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 1, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 847 - Health Care Quality Assurance › Section 847.008. Commission Duties

Sec. 847.008.  COMMISSION DUTIES.  (a)  The commission may require the commissioner to submit to the commission the documents reviewed by the department that substantiate the compliance of the health benefit plan issuer with applicable state statutory and regulatory requirements.
(b)  Documents submitted under Subsection (a) are proprietary and confidential information under Chapter 552, Government Code, and are not subject to subpoena.  The commission shall limit disclosure of the documents to commission employees who need the documentation to perform the duties of their job.  A commission employee may not further disclose the compliance documents.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 1, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 847 - Health Care Quality Assurance › Section 847.009. Memorandum of Understanding

Sec. 847.009.  MEMORANDUM OF UNDERSTANDING.  The commissioner and the commission must enter into a memorandum of understanding to specify the responsibilities of the department and the commission under this chapter.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 1, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 847 - Health Care Quality Assurance › Section 847.010. Enforcement

Sec. 847.010.  ENFORCEMENT.  This chapter may not be construed to prohibit the commissioner or the commission from enforcing laws or rules relating to:
(1)  the operation of a health benefit plan; or
(2)  violation of a contract.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 1, eff. June 17, 2005.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter A. General Provisions › Section 848.002. Exception: Delegated Entities

Sec. 848.002.  EXCEPTION:  DELEGATED ENTITIES.  (a)  This section applies only to an entity, other than a health maintenance organization, that:
(1)  by itself or through a subcontract with another entity, undertakes to arrange for or provide medical care or health care services to enrollees in exchange for predetermined payments on a prospective basis; and
(2)  accepts responsibility for performing functions that are required by:
(A)  Chapter 222, 251, 258, or 1272, as applicable, to a health maintenance organization; or
(B)  Chapter 843, Chapter 1271, Section 1367.053, Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507, as applicable, solely on behalf of health maintenance organizations.
(b)  An entity described by Subsection (a) is subject to Chapter 1272 and is not required to obtain a certificate of authority or determination of approval under this chapter.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter A. General Provisions › Section 848.003. Use of Insurance-Related Terms by Health Care Collaborative

Sec. 848.003.  USE OF INSURANCE-RELATED TERMS BY HEALTH CARE COLLABORATIVE.  A health care collaborative that is not an insurer or health maintenance organization may not use in its name, contracts, or literature:
(1)  the following words or initials:
(A)  "insurance";
(B)  "casualty";
(C)  "surety";
(D)  "mutual";
(E)  "health maintenance organization"; or
(F)  "HMO"; or
(2)  any other words or initials that are:
(A)  descriptive of the insurance, casualty, surety, or health maintenance organization business; or
(B)  deceptively similar to the name or description of an insurer, surety corporation, or health maintenance organization engaging in business in this state.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter A. General Provisions › Section 848.004. Applicability of Insurance Laws

Sec. 848.004.  APPLICABILITY OF INSURANCE LAWS.  (a)  An organization may not arrange for or provide health care services to enrollees on a prepaid or indemnity basis through health insurance or a health benefit plan, including a health care plan, as defined by Section 843.002, unless the organization as an insurer or health maintenance organization holds the appropriate certificate of authority issued under another chapter of this code.
(b)  Except as provided by Subsection (c), the following provisions of this code apply to a health care collaborative in the same manner and to the same extent as they apply to an individual or entity otherwise subject to the provision:
(1)  Section 38.001;
(2)  Subchapter A, Chapter 542;
(3)  Chapter 541;
(4)  Chapter 543;
(5)  Chapter 602;
(6)  Chapter 701;
(7)  Chapter 803; and
(8)  Chapter 804.
(c)  The remedies available under this chapter in the manner provided by Chapter 541 do not include:
(1)  a private cause of action under Subchapter D, Chapter 541; or
(2)  a class action under Subchapter F, Chapter 541.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter A. General Provisions › Section 848.005. Certain Information Confidential

Sec. 848.005.  CERTAIN INFORMATION CONFIDENTIAL.  (a)  Except as provided by Subsection (b), an application, filing, or report required under this chapter is public information subject to disclosure under Chapter 552, Government Code.
(b)  The following information is confidential and is not subject to disclosure under Chapter 552, Government Code:
(1)  a contract, agreement, or document that establishes another arrangement:
(A)  between a health care collaborative and a governmental or private entity for all or part of health care services provided or arranged for by the health care collaborative; or
(B)  between a health care collaborative and participating physicians and health care providers;
(2)  a written description of a contract, agreement, or other arrangement described by Subdivision (1);
(3)  information relating to bidding, pricing, or other trade secrets submitted to:
(A)  the department under Sections 848.057(a)(5) and (6); or
(B)  the attorney general under Section 848.059;
(4)  information relating to the diagnosis, treatment, or health of a patient who receives health care services from a health care collaborative under a contract for services; and
(5)  information relating to quality improvement or peer review activities of a health care collaborative.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter A. General Provisions › Section 848.006. Coverage by Health Care Collaborative Not Required

Sec. 848.006.  COVERAGE BY HEALTH CARE COLLABORATIVE NOT REQUIRED.  (a)  Except as provided by Subsection (b) and subject to Chapter 843 and Section 1301.0625, an individual may not be required to obtain or maintain coverage under:
(1)  an individual health insurance policy written through a health care collaborative; or
(2)  any plan or program for health care services provided on an individual basis through a health care collaborative.
(b)  This chapter does not require an individual to obtain or maintain health insurance coverage.
(c)  Subsection (a) does not apply to an individual:
(1)  who is required to obtain or maintain health benefit plan coverage:
(A)  written by an institution of higher education at which the individual is or will be enrolled as a student; or
(B)  under an order requiring medical support or dental support for a child; or
(2)  who voluntarily applies for benefits under a state administered program under Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq.), or Title XXI of the Social Security Act (42 U.S.C. Section 1397aa et seq.).
(d)  Except as provided by Subsection (e), a fine or penalty may not be imposed on an individual if the individual chooses not to obtain or maintain coverage described by Subsection (a).
(e)  Subsection (d) does not apply to a fine or penalty imposed on an individual described in Subsection (c) for the individual's failure to obtain or maintain health benefit plan coverage.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1150 (S.B. 550), Sec. 55, eff. September 1, 2018.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter B. Authority to Engage in Business › Section 848.051. Operation of Health Care Collaborative

Sec. 848.051.  OPERATION OF HEALTH CARE COLLABORATIVE.  A health care collaborative that is certified by the department under this chapter may provide or arrange to provide health care services under contract with a governmental or private entity.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter B. Authority to Engage in Business › Section 848.053. Compensation Advisory Committee; Sharing of Certain Data

Sec. 848.053.  COMPENSATION ADVISORY COMMITTEE; SHARING OF CERTAIN DATA.  (a)  The board of directors of a health care collaborative shall establish a compensation advisory committee to develop and make recommendations to the board regarding charges, fees, payments, distributions, or other compensation assessed for health care services provided by physicians or health care providers who participate in the health care collaborative.  The committee must include:
(1)  two members of the board of directors, of which one member is the hospital-based physician member, if the health care collaborative includes hospital-based physicians; and
(2)  if the health care collaborative consists of physicians and other health care providers:
(A)  a physician who is not a participant in the health care collaborative, selected by the physicians who are participants in the collaborative; and
(B)  a member selected by the other health care providers who participate in the collaborative.
(b)  A health care collaborative shall establish and enforce policies to prevent the sharing of charge, fee, and payment data among nonparticipating physicians and health care providers.
(c)  The compensation advisory committee shall make recommendations to the board of directors regarding all charges, fees, payments, distributions, or other compensation assessed for health care services provided by a physician or health care provider who participates in the health care collaborative.
(d)  Except as provided by Subsections (e) and (f), the board of directors and the compensation advisory committee may not use or consider a government payor's payment rates in setting the charges or fees for health care services provided by a physician or health care provider who participates in the health care collaborative.
(e)  The board of directors or the compensation advisory committee may use or consider a government payor's payment rates when setting the charges or fees for health care services paid by a government payor.
(f)  This section does not prohibit a reference to a government payor's payment rates in agreements with health maintenance organizations, insurers, or other payors.
(g)  After the compensation advisory committee submits a recommendation to the board of directors, the board shall formally approve or refuse the recommendation.
(h)  For purposes of this section, "government payor" includes:
(1)  Medicare;
(2)  Medicaid;
(3)  the state child health plan program; and
(4)  the TRICARE Military Health System.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter B. Authority to Engage in Business › Section 848.054. Certificate of Authority and Determination of Approval Required

Sec. 848.054.  CERTIFICATE OF AUTHORITY AND DETERMINATION OF APPROVAL REQUIRED.  (a)  An organization may not organize or operate a health care collaborative in this state unless the organization holds a certificate of authority issued under this chapter.
(b)  The commissioner shall adopt rules governing the application for a certificate of authority under this subchapter.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter B. Authority to Engage in Business › Section 848.055. Exceptions

Sec. 848.055.  EXCEPTIONS.  (a)  An organization is not required to obtain a certificate of authority under this chapter if the organization holds an appropriate certificate of authority issued under another chapter of this code.
(b)  A person is not required to obtain a certificate of authority under this chapter to the extent that the person is:
(1)  a physician engaged in the delivery of medical care; or
(2)  a health care provider engaged in the delivery of health care services other than medical care as part of a health maintenance organization delivery network.
(c)  A medical school, medical and dental unit, or health science center as described by Section 61.003, 61.501, or 74.601, Education Code, is not required to obtain a certificate of authority under this chapter to the extent that the medical school, medical and dental unit, or health science center contracts to deliver medical care services within a health care collaborative.  This chapter is otherwise applicable to a medical school, medical and dental unit, or health science center.
(d)  An entity licensed under the Health and Safety Code that employs a physician under a specific statutory authority is not required to obtain a certificate of authority under this chapter to the extent that the entity contracts to deliver medical care services and health care services within a health care collaborative.  This chapter is otherwise applicable to the entity.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter B. Authority to Engage in Business › Section 848.056. Application for Certificate of Authority

Sec. 848.056.  APPLICATION FOR CERTIFICATE OF AUTHORITY.  (a)  An organization may apply to the commissioner for and obtain a certificate of authority to organize and operate a health care collaborative.
(b)  An application for a certificate of authority must:
(1)  comply with all rules adopted by the commissioner;
(2)  be verified under oath by the applicant or an officer or other authorized representative of the applicant;
(3)  be reviewed by the division within the office of attorney general that is primarily responsible for enforcing the antitrust laws of this state and of the United States under Section 848.059;
(4)  demonstrate that the health care collaborative contracts with a sufficient number of primary care physicians in the health care collaborative's service area;
(5)  state that enrollees may obtain care from any physician or health care provider in the health care collaborative; and
(6)  identify a service area within which medical services are available and accessible to enrollees.
(c)  Not later than the 190th day after the date an applicant submits an application to the commissioner under this section, the commissioner shall approve or deny the application.
(d)  The commissioner by rule may:
(1)  extend the date by which an application is due under this section; and
(2)  require the disclosure of any additional information necessary to implement and administer this chapter, including information necessary to antitrust review and oversight.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter B. Authority to Engage in Business › Section 848.057. Requirements for Approval of Application

Sec. 848.057.  REQUIREMENTS FOR APPROVAL OF APPLICATION.  (a)  The commissioner shall issue a certificate of authority on payment of the application fee prescribed by Section 848.152 if the commissioner is satisfied that:
(1)  the applicant meets the requirements of Section 848.056;
(2)  with respect to health care services to be provided, the applicant:
(A)  has demonstrated the willingness and potential ability to ensure that the health care services will be provided in a manner that:
(i)  increases collaboration among health care providers and integrates health care services;
(ii)  promotes improvement in quality-based health care outcomes, patient safety, patient engagement, and coordination of services; and
(iii)  reduces the occurrence of potentially preventable events;
(B)  has processes that contain health care costs without jeopardizing the quality of patient care;
(C)  has processes to develop, compile, evaluate, and report statistics on performance measures relating to the quality and cost of health care services, the pattern of utilization of services, and the availability and accessibility of services; and
(D)  has processes to address complaints made by patients receiving services provided through the organization;
(3)  the applicant is in compliance with all rules adopted by the commissioner under Section 848.151;
(4)  the applicant has working capital and reserves sufficient to operate and maintain the health care collaborative and to arrange for services and expenses incurred by the health care collaborative;
(5)  the applicant's proposed health care collaborative is not likely to reduce competition in any market for physician, hospital, or ancillary health care services due to:
(A)  the size of the health care collaborative; or
(B)  the composition of the collaborative, including the distribution of physicians by specialty within the collaborative in relation to the number of competing health care providers in the health care collaborative's geographic market; and
(6)  the pro-competitive benefits of the applicant's proposed health care collaborative are likely to substantially outweigh the anticompetitive effects of any increase in market power.
(b)  A certificate of authority is effective for a period of one year, subject to Section 848.060(d).
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.
2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 848 - Health Care Collaboratives › Subchapter B. Authority to Engage in Business › Section 848.058. Denial of Certificate of Authority

Sec. 848.058.  DENIAL OF CERTIFICATE OF AUTHORITY.  (a)  The commissioner may not issue a certificate of authority if the commissioner determines that the applicant's proposed plan of operation does not meet the requirements of Section 848.057.
(b)  If the commissioner denies an application for a certificate of authority under Subsection (a), the commissioner shall notify the applicant that the plan is deficient and specify the deficiencies.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.01, eff. September 28, 2011.